INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 17, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Erie Inc. Corry Satellite Office 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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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report forms for all of the facilities within the drug and alcohol treatment project, the project failed to have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
The findings include:
The Staffing Requirements Facility Summary Report forms for the drug and alcohol treatment project's ten facilities were reviewed December 14 - 18, 2015. The project employs a total of 26.01 full-time counselors and counselor assistants. This number of full-time counselors and counselor assistants would require a minimum of 3 full-time clinical supervisors. The project currently employs 2 full-time clinical supervisors, as of December 18, 2015.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A current Clinical Supervisor (residential) who was carrying a caseload of clients has had the caseload removed and will carry no more than one client at any time in the future. This will increase the number of Clinical Supervisors in the project. The Program Supervisor (residential) will assure the clinical supervisor is not tasked with a case load of more than 1 client at any given time.
Division Director will also hire an additional Clinical Supervisor for the project. Division Director will also make sure that the project is in compliance moving forward.
Division Director will make sure the project will have one clinical supervisor for every 8 FTE counselors/counselor assistants.
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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 faciltiy failed to document that treatment and rehabilitation plans are updated at least every 60 days in five of five client records.
The findings include:
Ten client records were reviewed on December 17, 2015. All ten clients were in treatment for a period of time that would require treatment plan updates. Treatment plan updates were not documented at least every 60 days in client records #1, 7, 8, 9 and 10.
Client #1 was admitted on September 11, 2015. The first treatment and rehabilitation plan was documented on September 11, 2015. A treatment plan update was due to be completed by November 11, 2015. There was no treatment plan update documented in client record #1.
Client #7 was admitted on January 23, 2015 and discharged on May 21, 2015. Treatment plans / updates were documented on January 23 and February 20, 2015. A treatment plan update was due to be completed by April 20, 2015. There were no additional treatment plans / updates documented in client record #7.
Client #8 was admitted on March 20, 2015 and discharged on November 12, 2015. Treatment plans / updates were documented on March 6 and March 20, 2015. Treatment plan updates were due to be completed by May 20, July 20 and Sept 20, 2015. There were no additional treatment plans / updates documented in client record #8.
Client #9 was admitted on April 29, 2015 and discharged on October 22, 2015. Treatment plans / updates were documented on April 29 and May 20, 2015. Treatment plan updates were due to be completed by July 20 and Sept 20, 2015. There were no additional treatment plans / updates documented in client record #9.
Client #10 was admitted on February 6, 2015 and discharged on October 31, 2015. Treatment plans / updates were documented on February 6 and March 6, 2015. Treatment plan updates were due to be completed by May 6, July 6 and Sept 6, 2015. There were no additional treatment plans / updates documented in client record #10.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will review the requirements for treatment planning with all clinical staff. All Treatment Plans will be updated at least every 60 days.
Clinical Supervisor will review treatment plans in monthly chart audits and review findings in the agency's monthly quality improvement meeting.
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709.93(a) 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:
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Observations
Based on a review of client records, the facility failed to document a complete client record including a record of service and case consultations in 4 of 10 client records.
The findings include:
Ten client records were reviewed on December 17, 2015. All ten client records reviewed required the documentation of a record of service and case consultations. The facility failed to document the record of service and/or case consultations in client records, # 7, 8, 9 and 10.
Client #7 was admitted on January 23, 2015 and discharged on May 21, 2015. The record of service for the month of February 2015 was blank and there was no record of service documented for the months of March and April 2015. Per progress notes, services were provided to client #7 on 2/20/15, 2/27/15, 3/4/15, 3/5/15, 3/18/15, 3/25/15, 3/27/15 and 4/1/15.
Client #8 was admitted on March 20, 2015 and discharged on November 12, 2015. The first case consultation was documented on March 20, 2015. Quarterly case consultations were due to be completed by June 30, 2015 and September 30, 2015. There were no additional case consultations documented in client record #8.
Client #9 was admitted on April 29, 2015 and discharged on October 22, 2015. The record of service for May 2015 had one entry, May 1. There were no records of service documented for the months of June and July 2015. According to progress notes, services were provided on 5/6/15, 5/13/15, 5/20/15, 5/27/15, 6/3/15, 6/10/15, 6/17/15, 6/24/15, 6/25/15 and 7/1/15. The first case consultation was documented on May 20, 2015. A quarterly case consultation was due to be completed by September 30, 2015. There were no additional case consultations documented in client record #9.
Client #10 was admitted on February 6, 2015 and discharged on October 31, 2015. Case consultations were documented on February 27 and April 10, 2015. A quarterly case consultation was due to be completed by September 30, 2015. There were no additional case consultations documented in client record #10.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Clinical Supervisor will review documentation requirements for the record of service and case consultations with all clinical staff.
Clinical Supervisor will complete monthly chart audits looking specifically at record of service and case consultations and discuss her findings during the agency monthly quality improvement meeting. All records of service will be complete and case consultations will be completed at least quarterly. |