INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 15 - 17, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Erie Inc. - Crossroads 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(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of the personnel and training records, the facility failed to document that a core curriculum in clinical supervision was completed in two of two records.
The findings include:
On October 15, 2013, eight personnel and training records were reviewed. Two records were required to document a core curriculum in clinical supervision was completed.
Employee record #1 was hired on 6-28-2010 and was promoted on 9-10-2013. No documentation was available to show the employee functioned for 2 years as supervisors in the provision of clinical services. No documentation was available to show the employee completed a core curriculum in clinical supervision.
Employee record #2 was hired on 11-21-2011 and was promoted on 12-3-2012. No documentation was available to show the employee functioned for 2 years as supervisors in the provision of clinical services. No documentation was available to show the employee completed a core curriculum in clinical supervision.
The findings were reviewed with the project director and were not disputed.
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Plan of Correction
1) All new supervisors will be required to attend the DDAP Clinical Supervisory Training during the first available training upon hire.
2)The two current supervisors identified in observation #0031 will attend and complete the DDAP Clinical Supervisory Training, currently scheduled for December 9th-13th, 2013.
3)Division Director will review this requirement with all Program Directors and Program Supervisors during the next scheduled Management Team Meeting on December 17th, 2013. |
704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of personnel records, the facility failed to document that the clinical supervisor participated in monthly meetings with their supervisor to discuss their duties and performance for the first six months of employment in that position in one of two personnel record.
The findings include:
On October 15, 2013, eight personnel and training records were reviewed. Two records were required to document monthly meetings between the clinical supervisor and their supervisor for the first six months of employment in that position. The facility failed to document monthly supervision meetings in personnel record # 2.
Employee # 2 was hired at the project on 11-21-2011 and was promoted to the position of clinical supervisor on 12-3-2012. Monthly supervision meetings were required to take place in January, February, March, April, May and June 2013. There was no documentation of monthly supervision meetings in the personnel record of employee # 2.
The findings were reviewed with the project director and were not disputed.
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Plan of Correction
1) Division Director will review supervision requirement for the clinical supervisor position with the Program Director by 11/15/2013.
2) Program Director will be responsible to assure that supervisory sessions are conducted and documented appropriately.
3) Program Director will be responsible for making sure 6 months of consecutive supervisory sessions and notes are completed for the current clinical supervisor starting November 2013. |
709.32(c)(1) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication.
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Observations
Based on a review of client records, the facility failed to provide a complete Medication Administration Record in one of four client records reviewed.
The findings include:
Nine client records were reviewed on October 16, 2013. Four client records were from the detoxification activity and five client records were from the inpatient non-hospital - residential treatment activity. Four detoxification client records were required to include documentation of Medication Administration Records.
Client #2 was admitted to the detoxification activity on 9-11-2013 and discharged on 9-15-2013. The Medication Administration Record included an entry on 9-14-2013 at 3 am that the medication was given, but the initials of the staff person administering the medication was not documented.
The finding was reviewed with the project director and was not disputed.
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Plan of Correction
1) Agency Nurse Manager will train all nurses on Medication Administration Records and proper documentation by November 30th, 2013.
2) Nurse Manager will complete monthly chart reviews with a focus on Medication Administration Records and report findings in Agency's monthly QI/UR meeting. |
709.51(b)(3)(iii) LICENSURE Personal History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on the review of client records, the facility failed to provide a personal history in one of five records reviewed.
The findings include:
Nine client records were reviewed on October 16, 2013. Four client records were from the detoxification activity and five client records were from the inpatient non-hospital - residential treatment activity. Five client records from the inpatient non-hospital - residential treatment activity were required to provide a personal history. Client record #2 did not document a personal history.
Client record # 2 was admitted to residential treatment on 8-22-2013. A personal history was not documented as 10-16-2013.
This finding was discussed with the project director and was not disputed.
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Plan of Correction
1)Program Director will train and review all required time frames for clinical documentation by November 30th, 2013. Training will be documented on a Treatment Team Log or in a supervisory note.
2)Program Supervisor and Clinical Supervisor will complete weekly chart audits and report any deficiencies to the Program Director.
3)Program Director will complete monthly chart audits, specifically looking at personal histories and reviewing the findings with Division Director during monthly program meetings starting in December 2013.
4)Program Director will monitor and discuss chart audit results pertaining to personal histories in the agency monthly QI/UR meeting starting in November 2013. |
709.53(a) LICENSURE Complete Client Record
709.53. 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 the review of client records, the facility failed to provide a complete client record on each individual in five of five client records.
The findings include:
Nine client records were reviewed on October 16, 2013. Four client records were from the detoxification activity and five client records were from the inpatient non-hospital - residential treatment activity. Five residential client records were required to provide complete client records. The facility did not provide a complete client record for an individual in records #5, 6, 7, 8 and 9.
Client record #5 was admitted to treatment on 9-5-2013. The case consultation completed on 9-12-2013 did not include a disposition. The record of service did not include any group session entries.
Client record #6 was admitted to residential treatment on 8-22-2013. The case consultation on 8-29-2013 did not include a disposition or the staff members who participated. The record of service did not include any entries and was blank.
Client record #7 was admitted to residential treatment on 10-5-2013. The record of service did not include any entries and was blank.
Client record #8 was admitted to residential treatment on 6-20-2013 and discharged on 8-2-2013. The record of service did not include individual sessions for 6-23-2013 and 6-28-2013. The last entry on the record of service was 7-6-2013, but progress notes were documented and services were provided after that date. Follow-up documentation was missing.
Client record #9 was admitted 7-23-2013. The record of service did not include any group session entries.
The findings were discussed with the project director and were not disputed.
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Plan of Correction
1) Program Director will train all clinical staff on proper documentation for clinical records, specifically the record of service, case consultations, and follow-up documentation. This training will be documented in supervisory notes.
2)Program Supervisor and Clinical Supervisor will complete weekly chart audits to ensure clinical documentation is being completed correctly and when found not in compliance they will address it immediately and notify the Program Director.
3) Program Director will complete monthly chart audits and review the findings with the Division Director during monthly program Meetings.
4)Records of Service, Case Consultations, and Follow-up Documentation will be reviewed monthly in the agency QI/UR meeting for 6 months to track progress. |