INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on August 21 & 22 , 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Outpatient was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection and a plan of correction is due on October 26, 2007.
|
Plan of Correction
|
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
|
Observations
Based upon review of personnel records on August 8 through 14, 2007 and August 21, 2007, it was determined that the facility failed to document that employee #5 had completed the required four hours of TB/STD training.
|
Plan of Correction
counselor #5 as indicated in exit notes was hired on 8/07 as a counselor III. Training is not due. |
709.22(e)(1) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(1) Activities and accomplishments of the preceding year.
|
Observations
Based upon review of the 2005-2006 annual report during the corporate visit conducted on August 8, 9, 10, 13 and 14, 2007, it was determined that the facility failed to identify and include activities and accomplishments of the preceding year for each individual facility.
|
Plan of Correction
The annual report for the FY '07 will be printed and available for the current FY and every year thereafter and will include activities and accomplishments for the previous FY.
Person Responsible - Director of Development |
709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
|
Observations
Based upon review of the goals and objectives for the 2007-2008 fiscal year, it was determined that the facility failed to identify available resources and time frames for achievement. The majority of the goals and objectives do not include available resources and time frames for achievement.
|
Plan of Correction
Executive staff who are responsible for specific goal areas will develop and revise plans in specific goal areas in consulation with their respective Board Committees and available resources for approval at the September Board meeting and every September thereafter.
Person responsible - executive staff |
709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
|
Observations
Based upon a review of client records on 8/22/07, it was determined that 9 of 11 records contained consents to release information that were not informed consents or that exceeded the limitations imposed at 4 Pa. Code 255.5. The following client records contained consents to release information that indicated that the facility could release "recommendations"; however the facility did not define what exactly "recommendations" were. This was identified in client records #1, 2, 4, 5, 6, 7, 9, 10 & 11. The following client records contained consents to release information that allowed for the release of "recommendations" and/or treatment plans to funding sources, probation and parole and other government agencies. This was identified in client records #1, 2, 4, 5, 6, 7, 9 10 & 11.
|
Plan of Correction
The program supervisor will provide a training on Consents to Release Information:
1. Recommendations for level of care
2. Five areas which can be released to county and insurance resources
3. The importance of client's right to revoke consents.
The consents will be monitored through the QI process monthly to demonstrate the training implementation. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
|
Observations
Based upon a review of client records on 8/22/07, it was determined that the facility failed to complete preliminary treatment plans in a timely manner in 5 of 11 client records reviewed. No preliminary treatment plan was completed for client records # 2 & 9, preliminary treatment plans for client records # 1 & 5 had not been completed until 24 days after admission into the program and the preliminary treatment plan for client record #3 had not been completed until 60 days after admission.
|
Plan of Correction
The psychosocial assessment will include a preliminary treatment plan section. The clinical supervisor will monitor the process. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
|
Observations
Based upon a review of client records on 8/22/07, the facility failed to complete an individualized comprehensive treatment plan in a timely manner in 6 of 11 client records reviewed. Facility policy states that the treatment plan will be Completed by the 3rd treatment session. Comprehensive treatment plans had not yet been completed for client records #2, 3, 5 &9. Client record #7 was admitted on 4-10-07 but the comprehensive treatment plan had not been completed until 8-20-07. Client record #11 had been admitted on 12/20/06 but the comprehensive treatment plan had not been started until 3-20-07, and was incomplete and had not been signed by the client.
|
Plan of Correction
Counselors who are responsible for client records #2,3,5,7,9 & 11 will be trained and held responsible for the timing of the comprehensive treatment plan. The program supervisor is responsible for the training and the monitoring of training implementation. Failure to comply will result in appropriate disciplinary action. |
709.92(a)(1) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(1) Short and long-term goals for treatment as formulated by both staff and client.
|
Observations
Based upon a review of client records on 8/22/07, it was determined that the facility failed to formulate short and long term goals with the client in 5 of 11 client records reviewed. Short and long term goals were not formulated for clients records #2, 3, 5, 9 & 11.
|
Plan of Correction
The program supervisor is responsible for the training of counselors and the review of treatment plans - short and long-term goals. Training for counselors who were responsible for client records #2,3,5,9 & 11 will occur in supervisory sessions. The program supervisor is responsible for monitoring improvement and holding counselors responsible for improvement. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
|
Observations
Based upon a review of client records on 8/22/07, it was determined that the facility failed to identify the type and frequency of treatment services to be provided for the clients in 6 of 11 client records reviewed. The type and frequency of services were not identified for client records #2, 3, 5, 6, 9 & 11.
|
Plan of Correction
Treatment plan forms have identified type & frequency of services. Counselors are required to fill in the forms at the time of the development of the treatment plans. Counselors responsible for client records #2,3,5,6,9 & 11 will be trained and held responsible for compliance to this standard by the program supervisor. |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
|
Observations
Based upon a review of client records on 8/22/07, it was determined that the facility failed to identify the type of proposed support services to be provided for the client in 5 of 11 client records reviewed. Support services were not identified for client records #2, 3, 5, 9 & 11.
|
Plan of Correction
Treatment plan training for including support services for clients will be conducted by the program supervisor and will be reviewed for same when the program supervisor sign the treatment plans. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
|
Observations
Based upon a review of client records on 8/22/07, it was determined that the facility failed to complete treatment plan updates at least every 60 days for the clients in 5 of 11 client records reviewed. No treatment plan updates were completed for client records #5, 7, 9 &11. The treatment plan update for client #10, dated 12/21/06 had not been signed by the client.
|
Plan of Correction
The program supervisor will use the client census in clinical meetings and supervisory sessions to determine the completion of treatment plan review every 60 days. The program supervisor will hold counselors responsible for the compliance to this standard. |
709.92(d) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
|
Observations
Based upon a review of client records on 8/22/07, it was not possible to determine if the facility provided counseling on a regular and scheduled basis for the clients in 4 of 11 client records reviewed. Client records #2, 5, 10 & 11 had incomplete and/or missing records of service and progress notes.
|
Plan of Correction
The Client Record of Service is to be completed for every scheduled client contact. Counselors are responsible for this documentation and progress notes when the client is seen in individual and group sessions. Counselors responsible for client records #2,5,10 & 11 will receive appropriate training and disciplinary action by the program supervisor |
709.93(a)(2) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(2) Medication records.
|
Observations
Based upon a review of client records on 8/22/07, it was determined that the facility failed to properly document the dosage and/or frequency of use of medications for clients in 3 of 11 client records reviewed. Client records #5 & 7 did not include the dosage of medication that the client was taking and record #11 did not indicate the frequency that the client was to take the medications.
|
Plan of Correction
Program Supervisor will train clinical personnel as to the appropriate information collection regarding medication:
1. Type
2. Dosage
3. Frequency
4. medical problem
5. Applicability of information when none is taken
This training will be reviewed in the QI process monthly for implementation. |
709.93(a)(3) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(3) Record of services provided.
|
Observations
Based upon a review of client records on 8/22/07, it was determined that the facility failed to maintain a complete and up to date record of services for clients in 4 of 11 client records reviewed. There was no record of services in client record #5, the record of services in client record #2, where the last date of counseling was documented as 6/13/07, lacked any entries beyond 5/23/07, client record #10, where the last date of counseling was documented as 3/18/07, lacked any entries beyond 1/31/07. Client record #11 did not have entries for dates which coincided with the dates on the documented progress notes.
|
Plan of Correction
Program Supervisor will re-train and monitor for compliance to this standard in supervisory sessions for counselors responsible for client records #2,5, 10 & 11. Appropriate disciplinary action will be implemented where appropriate. |
709.93(a)(5) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(5) Progress notes.
|
Observations
Based upon a review of client records on 8/22/07, it was determined that progress notes were missing in 4 of 11 client records reviewed. Progress notes were not consistently completed in client records #2, 5, 10 & 11.
|
Plan of Correction
Counselors responsible for client records #2,5,10 & 11 will be held responsible for lack of progress notes through reprimands by the program supervisor. |
709.93(a)(8) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
|
Observations
Based upon a review of client records on 8/22/07, case consultations were not completed in 3 of 11 records reviewed. No case consultations were completed for clients #2, 3 & 11.
|
Plan of Correction
The program supervisor will utilize the client census in clinical meetings and supervisory sessionis to hold case consultations. They will be documented and signed by the supervisor at the time of the consultation. Failure to follow this correction will result in appropriate disciplinary action. |
709.93(a)(9) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(9) Aftercare plan, if applicable.
|
Observations
Based upon a review of client records on 8/22/07, aftercare plans in 2 of 3 client records reviewed failed to provide specific dates for the client to accomplish goals and action steps for aftercare and 1 of 3 records lacked an aftercare plan. Client records #8 & 10 lacked specific dates for the client to accomplish goals and action steps for aftercare. Client record #9 had no aftercare plan documented.
|
Plan of Correction
The program supervisor will provide training for completing aftercare plans correctly with the clinical personnel responsible for client records #8, 9 & 10. These trainings will be documented as supervisory sessions and staff held accountable. |
709.93(a)(10) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(10) Discharge summary.
|
Observations
Based upon a review of client records on 8/22/07, it was determined that in 1 of 3 client records the discharge summary was not completed within 7 days of the date of discharge as required by facility procedure. Client record #9 lacked a discharge summary.
|
Plan of Correction
The program supervisor will audit all discharged client records on a weekly basis. Failure to complete a discharge summary in 7 days of discharge date will result in appropriate warnings and disciplinary action. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
|
Observations
Based upon a review of client records on 8/22/07, it was determined that 3 of 3 client records lacked documentation that a follow up for discharged clients had been completed.
Client records #8, 9 & 10 failed to document that a follow up had been completed.
|
Plan of Correction
The correction for the lack of following procedure is:
Program Supervisor will be responsible for monitoring that this is done in administrative and clinical meetings on a weekly basis. Minutes will reflect this review. Failure to comply will result in disciplinary actions for all employees who have not followed the procedure. |