INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted from May 31, 2011 through June 1, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Inc., Fountain Springs 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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709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to document physical examinations in accordance with the project's policies and procedures in six out of seven client records.
The findings include:
On May 31, 2011 seven client records were reviewed for a physical examination. The facility neglected to record the physician's impressions in the physical examination in four client records, # 1, 2, 4, and 6, additionally, the physical exam was documented late in client record #4. Two client records, # 5 and # 7, did not include documentation of a physical examinations.
The facility policy titled; PHYSICAL EXAMINATION LABORATORY STUDIES states:
"A client entering a Gaudenzia (residential) program shall receive a complete physical examination by a qualified physician within 7 days of admission (DOH), except on holiday or weekend. Documentation of the results of the physical examination shall include but not be limited to: evidence of injury, neurological findings, investigation of the organ systems for potential infectious disease, pulmonary, liver and cardiac abnormalities, dermatological sequelae of addiction, vital signs, examination of general appearance, head, ears, eyes, nose, throat, chest, abdomen, extremities, skin assessment, concurrent problems and the physician's overall impression of the client."
Client # 1 was admitted on April 4, 2011. The physical examination was completed on April 6, 2011, but did not include documentation of the physician's overall impression of the client.
Client # 2 was admitted on May 9, 2011. The physical examination was completed on May 10, 2010 but did not include documentation of the physician's overall impression of the client.
Client # 4 was admitted on September 30, 2010. The physical examination was due by September 12, 2010 but was not completed until December 21, 2010. The physical examination did not include documentation of the physician's overall impression of the client.
Client # 5 was admitted on August 4, 2010. The physical examination was due to be completed by August 13, 2010, but had not been documented as of May 31, 2011.
Client # 6 was admitted on February 16, 2011. The physical examination was completed on February 23, 2011, but did not include documentation of the physician's overall impression of the client.
Client # 7 was admitted on October 29, 2010. The physical examination was due to be completed by November 9, 2010, but had not been documented as of May 31, 2011.
A conversation was held with the Facility Director on June 1, 2011. The Facility Director confirmed the lack of documentation of the physician's impressions.
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Plan of Correction
Every client entering Gaudenzia Fountain Springs shall receive a complete physical examination by a qualified physician within seven (7) days of admission; documentation of physician overall impression of client will be recorded on every physical form. The nursing staff will review every physical form for completeness and file promptly in the client record. The Program Director will review with nursing staff and Clinical Supervisor the facility policy of physical examinations including the documentation needed in meeting on July 8, 2011. The Clinical Supervisor will review new client charts during weekly clinical meetings to ensure compliance with the physical policy. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. 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 the review of client records, the facility's policy and procedures manual, and an interview with the Facility Director and Clinical Supervisor, the facility failed to document an individual treatment and rehabilitation plan in accordance with the facility's policy and procedures in four of seven client records.
The findings include:
On May 31, 2011, seven client records requiring treatment and rehabilitation plans were reviewed. The facility did not document an individual treatment and rehabilitation plan based on information collected in client histories within the first three days of the client's admission, as per facility policy, in client records #4, 5, and 6.
The facility's policy titled "PROCEDURE FOR INDIVIDUAL TREATMENT & REHABILITATION PLAN" States:
"An individualized treatment and rehabilitation plan will be developed with each client after the completion of the client's psycho-social evaluation. The counselor will create, with the client, a proposed treatment plan, based on information collected in patient histories, the bio-psycho-social and assessment and the clients [sic] problem list. The plan will be discussed with the client and changes made upon client request as appropriate." "The treatment plan will be signed by the Client, the Primary Counselor, the Clinical Supervisor, physician (when applicable) and placed in the client record. Completion of the treatment plan will be noted in the counselor's progress note for that day of service, within 3 days of admission (residential) or by the third session (outpatient).Chesapeake region requires an initial TP within 24 hours)."
Client # 4 was admitted on September 30, 2010. The treatment and rehabilitation plan was completed prior to the completion of the biopsychosocial assessment. The psychosocial assessment was completed on October 1, 2010 and the treatment plan was completed on September 30, 2010.
Client # 5 was admitted on August 4, 2010. The treatment and rehabilitation plan was completed prior to the completion of the biopsychosocial assessment. The psychosocial assessment was completed on August 5, 2010 and the treatment plan was completed on August 4, 2010.
Client # 6 was admitted on February 16, 2011. The treatment and rehabilitation plan was completed prior to the completion of the biopsychosocial assessment. The psychosocial assessment was completed on February 17, 2011 and the treatment plan was completed on February 16, 2011.
This was confirmed with the Facility Director and Clinical Supervisor on June 1, 2011.
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Plan of Correction
The procedure for individual treatment and rehabilitation plan will be followed per the policy contained in the facility policy and procedures manual. An individualized treatment plan will be developed with each client after the completion of the client's biopsychosocial evaluation. The biopsychosocial evaluation and assessment will be completed by the counselor within three (3) days of admission. Completion of the treatment plan will be noted in the counselor's progress note for that day of service, within three (3) days of admission. The Clinical Supervisor will review with the clinical staff the procedure for individual treatment and rehabiliation plans during clinical meeting on July 8, 2011. The Clinical Supervisor will review client treatment plans and the supporting case note in preparation for QI meetings monthly and weekly during clinical meetings to ensure compliance. |
709.54(c) LICENSURE Follow-up policy
709.54. Project management services.
(c) The project shall develop a written client follow-up policy.
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Observations
Based on a review of the facility's policy and procedure manual, the facility failed to develop a written client follow-up policy that accurately reflects their follow-up process.
The findings include:
From May 9, 2011 through May 11, 2011, the facility's policy and procedure manual was reviewed. The facility had two conflicting procedures regarding attempts to follow up on clients. The facility's policy titled: "Follow Up Information," states:
" All clients are followed up after discharge. Follow up information shall be conducted for each client after discharge from the program, unless there is specific client refusal for follow up. Each program will maintain a follow up policy outlining the specific steps taken. The follow up log binder will house the documentation of each follow up attempt. Primary Counselors and/or any designee of the Program/Clinical Supervisor or Director shall assume responsibility for client follow up. In the case where a client has been referred to a specific outside resource for continued care post discharge from the project, follow up should be completed via a telephone call with the resource within one week of the client's initial referral appointment to the resource. Once the attempt has been made and documented in the follow up log binder, a program may consider its obligation to the individual fulfilled. This procedure will follow for client's who are nor referred after discharge. The worker will attempt to contact the client directly via telephone and document the findings in the log binder. In instances where the client refuses follow up, the refusal shall be documented on the Follow Up form and in a progress note [remember to state the reason for the refusal in the note and on the form]. Where clients are not referred after discharge, the clinical supervisor or their designee will call the client in 30 days. Contact will be logged in the Follow Up Log binder.
Follow up information shall include the client's status with the referral resource/resource disposition, sobriety status, 12 step/support group involvement, and overall progress with aftercare goals. "
The facility's policy and procedure manual contained a second written policy titled: "FOLLOW UP INFORMATION." This second policy states:
"Regardless of the type of discharge, attempts are made to follow up all clients post discharge. When a client has been discharged and referred to an outside source, the program will, with the written consent of the client and within one week from the day the referral is to be completed, attempt to determine from the resource the disposition of the referral. Once the attempt has been made and documented in the follow up log book, the program may consider its obligation to the individual fulfilled. The administrative assistant or designee by the program supervisor. When the client refuses a referral after discharge (this includes ASA, Therapeutic Discharge or completions who refuse the next level of care on the continuum), an attempt will be made by the administrative assistant or supervisor's designee, to follow-up the discharged client's progress and well being and to maintain an opportunity for either re-admission to the program or admission to the next level of care on the continuum should circumstances warrant it as necessary and appropriate. This will occur within the 7 days post discharge. Information shall be kept in the follow up log binder."
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Plan of Correction
The facility's policy and procedures manual was reviewed May 9, 2011 through May 11, 2011 at Gaudenzia's Corporate Office. According to corporate guidelines, no individual facility may change any policy or form to suit facility needs. This citation regarding conflicting policies was reported to the Central Region Director, CQI Director and Northern Tier Division Director. The CQI Director revised the follow-up policy on June 15, 2011. All Gaudenzia policies are now updated on the Gaudenzia web site forms page. All updates will be discussed monthly in the CQI meeting and clarified by the CQI Director. The Program Director will review the revised follow-up policy in an all staff meeting on July 8, 2011 and the revised follow-up policy will be implemented immediately afterwards. The new policy states that within seven (7) days of the date of a referral appointment made for a client leaving treatment, the referral shall be contacted by the counselor and for clients ending treatment without a referral appointment, the client shall be contacted directly within thirty (30) days. All follow-ups will be documented and maintained in the follow-up log binder. The Clinical Supervisor will ensure compliance by reviewing the follow-up log binder monthly and discussing the status of follow-ups during clinical meetings. |