INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 15, 2013 by staff from the Department of Drug and Alcohol Program's Division of 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:
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Plan of Correction
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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.
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Observations
Based on a review of client records, the facility failed to document a preliminary treatment plan as per agency policy in five of seven client records.
The findings include:
Seven outpatient client records were reviewed on May 15, 2013. A preliminary treatment plan, per agency policy, is to be completed at the time of first contact/session with the counselor. The facility failed to document a preliminary treatment plan at the time of first contact/session with the counselor in five of seven client records.
Client #1 was admitted to outpatient treatment on February 25, 2013 and the admission session took place on that date. The preliminary treatment plan was due to be completed on February 25, 2013. There was no documentation of a preliminary treatment plan.
Client #2 was admitted to outpatient treatment on February 19, 2013 and the admission session took place on that date. The preliminary treatment plan was due to be completed by February 19, 2013 . There was no documentation of a preliminary treatment plan.
Client #11 was admitted to outpatient treatment on November 10, 2012 and the admission session took place on that date. The preliminary treatment plan was due to be completed by November 10, 2012. There was no documentation of a preliminary treatment plan.
Client #12 was admitted to outpatient treatment on January 24, 2013 and the admission session took place on that date. The preliminary treatment plan was due to be completed by January 24, 2013 . There was no documentation of a preliminary treatment plan.
Client #15 was admitted to outpatient treatment on December 18, 2012, and the admission session took place on that date. The preliminary treatment plan was due to be completed by December 18, 2012. There was no documentation of a preliminary treatment plan.
The findings were confirmed by the clinical supervisor.
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Plan of Correction
Effective immediately, counselors will complete initial/preliminary treatment plans at the first counseling session.
As of June 10, 2013 all admission packets include the initial treatment plan form in order to be completed.
The Program Supervisor will monitor compliance via monthly quality improvement audits and outcomes will be discussed at supervisory sessions with clinical staff.
The Program Director will be responsible for oversight. |
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:
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Observations
Based on a client record review, the facility failed to develop individual treatment and rehabilitation plans with the client as stated in agency policy in five of seven client records.
The findings include:
Fifteen client records were reviewed on May 15, 2013. Seven of the fifteen client records were required to have individual treatment and rehabilitation plans developed with the client within 30 days of admission, as per agency policy.
Client records #1, 2, 11, 12, and 15 did not contain individual treatment and rehabilitation plans that were developed with the client within 30 days of admission.
Client #1 was admitted to outpatient treatment on February 25, 2013. An individual treatment and rehabilitation plan was due to be developed with the client by March 27, 2013. There was no individual treatment plan developed for this client.
Client #2 was admitted to outpatient treatment on February 19, 2013. An individual treatment and rehabilitation plan was due to be developed with the client by March 21, 2013. There was no individual treatment plan developed for this client.
Client #11 was admitted to outpatient treatment on April 12, 2012. An individual treatment and rehabilitation plan was due to be developed with the client by May 3, 2012. The individual treatment and rehabilitation plan was developed on May 29, 2012.
Client #8 was admitted to outpatient treatment on April 18, 2012. An individual treatment and rehabilitation plan was due to be developed with the client by May 9, 2012. The individual treatment and rehabilitation plan was developed on July 16, 2012.
Client #11 was admitted to outpatient treatment on April 2, 2012. An individual treatment and rehabilitation plan was due to be developed with the client by April 23, 2012. The individual treatment and rehabilitation plan was developed on April 26, 2012.
The findings were reviewed with the facility director and the clinical supervisor and were not disputed.
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Plan of Correction
An in-service will be given by the Program Director and Program Supervisor on July 5, 2013 to review Gaudenzia Policies and Procedures regarding timeframes for completion of treatment plans.
Clinicians will complete an individualized treatment plan with the client within 30 days of the admission session.
Due to strict DOC attendance regulations, treatment plans will be developed monthly in order to ensure compliance.
A treatment plan will be added to the client record for those that are still active in treatment upon their next available session.
The Program Supervisor will then monitor adherence to these policies through regular monthly audits of the clinical charts. The findings of these audits will be monitored as a part of the Continuous Quality Improvement process.
The Program Director will maintain oversight. |
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.
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Observations
Based on a review of client records the facility failed to document a treatment plan with short and long term treatment goals in four of seven clients records, as required.
The findings include:
Seven client records that required treatment plans including short and long term goals for treatment were reviewed on May 15, 2013. The facility failed to document short and long term treatment goals in client records # 1, 2, 11, 15, and were documented late in record #12.
Client # 1 was admitted into treatment on February 25, 2013. A treatment plan was due by the third session. The treatment plan did not include short and long term treatment goals.
Client # 2 was admitted into treatment on February 19, 2013. A treatment plan was due by the third session. The treatment plan did not include short and long term treatment goals.
Client # 11 was admitted into treatment on November 10, 2012. A treatment plan was due by the third session. The treatment plan did not include short and long term treatment goals.
Client # 12 was admitted into treatment on January 24, 2013. A treatment plan was due by the third session. The treatment plan including short and long term goals was submitted after the third session.
Client # 15 was admitted into treatment on December 18, 2012. A treatment plan was due by the third session. The treatment plan did not include short and long term treatment goals.
The facility director confirmed the findings.
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Plan of Correction
Effective immediately, counselors will identify short/long term goals on the treatment plan per documentation procedures.
Due to the strict DOC attendance regulations, treatment plans will be developed monthly in order to ensure compliance.
An in-service training was held on June 14, 2013 by the Director and Program Supervisor to relay current policies and procedures regarding recordkeeping and timelines for completion.
A treatment plan will be added to the client record for those that are still active in treatment upon their next session.
The Program Supervisor will monitor compliance utilizing the monthly CQI process.
The Program Director will maintain oversight of these practices. |
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.
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Observations
Based on a review of client records the facility failed to document a treatment plan with type and frequency of treatment and rehabilitation services.
The findings include:
Seven client records that required treatment plans including type and frequency of treatment and rehabilitation services were reviewed on May 15, 2013. The facility failed to document type and frequency of treatment and rehabilitation services in client records # 1, 2, 11, 15, and were documented late in record #12.
Client # 1 was admitted into treatment on February 25, 2013. A treatment plan was due by the third session. The treatment plan did not include type and frequency of treatment and rehabilitation services.
Client # 2 was admitted into treatment on February 19, 2013. A treatment plan was due by the third session. The treatment plan did not include type and frequency of treatment and rehabilitation services.
Client # 11 was admitted into treatment on November 10, 2012. A treatment plan was due by the third session. The treatment plan did not include type and frequency of treatment and rehabilitation services.
Client # 12 was admitted into treatment on January 24, 2013. A treatment plan was due by the third session. The treatment plan including type and frequency of treatment and rehabilitation services was submitted after the third session.
Client # 15 was admitted into treatment on December 18, 2012. A treatment plan was due by the third session. The treatment plan did not include type and frequency of treatment and rehabilitation services.
The facility director confirmed the findings.
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Plan of Correction
Effective immediately, counselors will identify type and frequency of treatment and rehabilitation services per documentation procedures.
Due to the strict DOC attendance regulations, treatment plans will be developed monthly in order to ensure compliance.
An in-service training was held on June 14, 2013 by the Director and Program Supervisor to relay current policies and procedures regarding recordkeepding and timelines for completion.
A treatment plan will be added to the client record for those that are still active in treatment upon their next session.
The Program Supervisor will monitor compliance utilizing the monthly CQI process.
The Program Director will maintain oversight of these practices. |
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.
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Observations
Based on a review of client records the facility failed to document a treatment plan with the proposed type of support services.
The findings include:
Seven client records that required treatment plans including the proposed type of support services were reviewed on May 15, 2013. The facility failed to document the proposed type of support services in client records # 1, 2, 11, 15, and were documented late in record #12.
Client # 1 was admitted into treatment on February 25, 2013. A treatment plan was due by the third session. The treatment plan did not include the proposed type of support services
Client # 2 was admitted into treatment on February 19, 2013. A treatment plan was due by the third session. The treatment plan did not include the proposed type of support services
Client # 11 was admitted into treatment on November 10, 2012. A treatment plan was due by the third session. The treatment plan did not include the proposed type of support services
Client # 12 was admitted into treatment on January 24, 2013. A treatment plan was due by the third session. The treatment plan including the proposed type of support services was submitted after the third session.
Client # 15 was admitted into treatment on December 18, 2012. A treatment plan was due by the third session. The treatment plan did not include the proposed type of support services
The facility director confirmed the findings.
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Plan of Correction
Effective immediately, counselors will document the proposed type of support services on the treatment plan.
Due to the strict DOC attendance regulations, treatment plans will be developed monthly in order to ensure compliance.
An in-service training was held on June 14, 2013 by the Program Director and Program Supervisor to relay current policies and procedures regarding recordkeeping and timelines for completion.
Treatment plans will be reviewed by the Program Supervisor, prior to being signed, for compliance regarding full completion of the stated form.
A treatment plan will be added to the client record for those that are still active in treatment upon their next session.
The Program Supervisor will monitor compliance utilizing the monthly CQI process and discuss outcomes in supervisory sessions.
The Program Director will maintain oversight. |
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.
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Observations
Based on a review of client records, the facility failed to document a treatment plan update in three of four client records.
The findings include:
Four client records that required treatment plan updates were reviewed on May 15, 2013. Per the facility policy, treatment plan updates are required to be completed within 60 days of the comprehensive treatment plan. The facility failed to document a treatment plan update in client records #1, 2 and 11.
Client #1 was admitted on February 25, 2013. As of May 15, 2013 no treatment plan or treatment plan update was documented.
Client #2 was admitted on February 19, 2013. As of May 15, 2013 no treatment plan or treatment plan update was documented.
Client #11 was admitted on November 10, 2012. As of May 15, 2013 no treatment plan or treatment plan update was documented.
The facility director confirmed the findings.
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Plan of Correction
Effective immediately, counselors will devise a treatment plan update within 60 days. Due to the strict attendance regulations, SIP clients will receive treatment plan updates on a monthly basis to ensure compliance.
A treatment plan will be added to the client record for those that are still active in treatment upon their next session.
The Program Supervisor will utilize a tracking system to establish end dates for treatment plans to ensure clinicians complete them in the required time frame. Treatment plan updates wiill also be reviewed by the Program Supervisor, prior to being signed, for compliance.
The Program Supervisor will monitor compliance via the monthly CQI process and outcomes will be reviewed in supervision.
The Program Director will be responsible for oversight. |
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.
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Observations
Based on a review of client records, the facility failed to document a case consultation quarterly in three of five client records.
The findings include:
Five outpatient client records that required case consultations were reviewed on May 15, 2013. Per agency policy, case consultations shall be completed every 90 days. Case consultations were required in five client records. The facility did not document a case consultation within the 90 day time frame in client records 11, 12, and 15.
Client #11 was admitted on November 10, 2012. The case consultations were due by February 8, 2013 and May 10, 2013. There were no case consultations completed for this client record.
Client #12 was admitted on January 24, 2013. The case consultation was due by April 24, 2013. There was no case consultation completed for this client record.
Client #15 was admitted on December 18, 2013. The case consultation was due by March 16, 2013. There was no case consultation completed for this client record.
The findings were confirmed by the facility director.
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Plan of Correction
Effective immediately, counselors will document case consultations, at a minimum of every 90 days.
The Program Supervisor will utilize a similar tracking system to the treatment plans to establish and monitor due dates for case consultations.
The Program Supervisor will utilize monthly quality improvement audits and discuss the findings in supervisory session with clinical staff biweekly.
Case consultations were completed and filed in charts #11, #12 and #15 as of June 19, 2013.
All clinical staff as well as the Program and Clinical Supervisor will be scheduled to be trained and/or retrained, via the Training Institute, on Clinical Recordkeeping and Current Standards within the next six months.
The Program Director will be responsible for oversight. |