INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on June 26, 2019, by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the on-site inspection, Gaudenzia Inc. Fulton County 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:
|
Plan of Correction
|
704.9(a) LICENSURE Counselor Asst Supervision
704.9. Supervision of counselor assistant.
(a) Supervision. A counselor assistant shall be supervised by a full-time clinical supervisor or counselor who meets the qualifications in 704.6 or 704.7 (relating to qualifications for the position of clinical supervisor; and qualifications for the position of counselor).
|
Observations
Based on a review of staff records conducted during the on-site inspection on June 26, 2019, and based on staff interviews conducted during the on-site inspection on June 26, 2019, the facility failed to ensure that its counselor assistants were supervised by a full-time clinical supervisor or counselor. Staff Person #5 was hired as a bachelor ' s degree counselor on March 11, 2019. From the staff person ' s hire date until the on-site inspection the staff person had been supervised by the facility director. These findings were reviewed with facility staff as part of the licensing process.
|
Plan of Correction
Effective July 15th, 2019-The Counselor Assistant at this location will be supervised by a full time Counselor.
This individual will provide and document weekly, face to face, supervision until requirements have been met to be promoted to a Counselor.
Ongoing, should the facility hire a counselor assistant that individual would be assigned to a full time counselor or clinical supervisor for supervision as per the regulation. |
704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
|
Observations
Based on a review of the project ' s documents submitted to the Department on May 23, 2019, the project failed to follow its comprehensive staff development program for agency personnel. The overall training plan for the project was not completed until May 16, 2019, but the projects Plan for Assessing Staff Training Needs in the Project ' s Policy and Procedure Manual reads, " The training plan shall be ready for implementation effective Jan. 31st of each year. " These findings were reviewed with facility staff as part of the licensing process.
|
Plan of Correction
The relevant Gaudenzia Policy has been revised to state that, "Program-level training needs assessments are due to the Training department by the end of January of each year. Upon receipt of the program-level annual assessments of staff training needs, the Director of Training and Education, in collaboration with the Project Director, will review the assessments in detail and develop a plan to address the training needs of the agency. The annual agency-wide training plan shall be ready for implementation no later than April 30th of each year." The Gaudenzia Director of Training and Education will ensure that this is completed within the designated timeframe each year. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
|
Observations
Based on a review of the project ' s staff records conducted on June 3-4, 2019, the project failed to ensure that all of its staff had the appropriate fire extinguisher training.Staff Person #1, the project director, was hired on March 4, 2019, but the staff person did not receive fire extinguisher training. These findings were reviewed with facility staff as part of the licensing process.
|
Plan of Correction
The Project Director completed this training on 6/7/19 and documentation of this has been placed in his file. All relevant staff within the HR and Training departments will review the DDAP 705.10 (c) (4) - 705.28 (c) (4) regulations by 7/31/19, and as the head of the Training department, the Director of Training and Education will be ultimately responsible for ensuring that all staff (to include administrative staff) receive required fire extinguisher training upon hire. Training department staff will review all staff files during the orientation process to ensure that this training is completed. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
|
Observations
Based on a review of the project ' s staff records conducted on June 3-4, 2019, the project failed to ensure that all of its staff had the appropriate emergency training.Staff Person #1, the project director, was hired on March 4, 2019, but the staff person did not receive emergency training. These findings were reviewed with facility staff as part of the licensing process.
|
Plan of Correction
The Project Director completed this training on 6/7/19 and documentation of this has been placed in his file. All relevant staff within the HR and Training departments will review the DDAP 705.28 (d) (3) regulations by 7/31/19, and as the head of the Training department, the Director of Training and Education will be ultimately responsible for ensuring that all staff (to include administrative staff) receive required emergency procedure training upon hire. Training department staff will review all staff files during the orientation process to ensure that this training is completed. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
|
Observations
Based on a review of the project ' s policy and procedure manual conducted at the Department ' s headquarters from May 21-24, 2019, the facility failed to complete its admission and treatment documentation within the time frames adopted by its governing body.The project ' s policy and procedure manual reads that comprehensive/individualized treatment plans are to be completed 30 days from the preliminary for all outpatient programs.The facility is an outpatient program. Client #1 was admitted for outpatient treatment on October 29, 2018, and was an active client at the time of the inspection. The client ' s preliminary treatment plan was dated November 14, 2018, but the facility did not complete an individualized treatment plan until January 2, 2019. Client #3 was admitted for outpatient treatment on December 10, 2018, and was an active client at the time of the inspection. The client ' s preliminary treatment plan was dated December 21, 2018, but the facility did not complete an individualized treatment plan until February 8, 2019. These findings were reviewed with facility staff as part of the licensing process.
|
Plan of Correction
During a clinical meeting, scheduled for July 30th, 2019~Facility Director will review the policies and procedures related to initial & comprehensive/individualized treatment plans. The review will include the expectation of completing the comprehensive treatment plan within 30 days of the preliminary treatment being done.
Ongoing the facility director will monitor the adherence to this policy through monthly open and closed chart audits that are completed. If a counselor is not following the policy, supervision will be completed and documented. |
709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
|
Observations
Based on a review of client records conducted during the on-site inspection on June 26, 2019, the facility failed to acquire documentation from clients that it informed the clients of all of their rights in six of six outpatient records and two of two intake evaluation and referral client records reviewed. The clients' rights forms that the clients sign at the facility do not inform the clients of the following: Clients have the right to appeal a decision limiting access to their records to the director. .These findings were reviewed with facility staff as part of the licensing process.
|
Plan of Correction
The Continuous Quality Improvement Director has revised the Gaudenzia Client Bill of Rights to accurately reflect the DDAP 709.30 regulations regarding a client's right to inspect their own record and actions they make take in this regard. The document now states that, "The following rights are affirmed... The right to examine one's own record within the guidelines approved by the agency in accordance with Federal regulations 42 CFR, and rebut any information in their record by inserting a counter statement of clarification or correction. The agency may temporarily remove portions of the record prior to inspection if the Director determines that the information may be detrimental if presented to the client. Reasons for removal of sections will be documented in the record. Clients have the right to appeal a decision limiting access to their records to the director. Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records." This revised Bill of Rights document will be distributed to all programs by 7/26/19. The Program Director will review it with all staff and it will be incorporated into the client orientation manuals and signed by all active clients by 8/2/19. The Program Director will ensure that as a part of the regular, monthly CQI Chart Audit process, the current version of the Client Bill of Rights is being completed. |
709.30 (5) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
|
Observations
Based on a review of client records conducted during the on-site inspection on June 26, 2019, the facility failed to acquire documentation from clients that it informed the clients of all of their rights in six of six outpatient records and two of two intake evaluation and referral records. The clients' rights forms that the clients sign at the facility do not inform the clients of the following: Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records. These findings were reviewed with facility staff as part of the licensing process.
|
Plan of Correction
The Continuous Quality Improvement Director has revised the Gaudenzia Client Bill of Rights to accurately reflect the DDAP 709.30 regulations regarding a client's right to inspect their own record and actions they make take in this regard. The document now states that, "The following rights are affirmed... The right to examine one's own record within the guidelines approved by the agency in accordance with Federal regulations 42 CFR, and rebut any information in their record by inserting a counter statement of clarification or correction. The agency may temporarily remove portions of the record prior to inspection if the Director determines that the information may be detrimental if presented to the client. Reasons for removal of sections will be documented in the record. Clients have the right to appeal a decision limiting access to their records to the director. Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records." This revised Bill of Rights document will be distributed to all programs by 7/26/19. The Program Director will review it with all staff and it will be incorporated into the client orientation manuals and signed by all active clients by 8/2/19. The Program Director will ensure that as a part of the regular, monthly CQI Chart Audit process, the current version of the Client Bill of Rights is being completed. |
709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
|
Observations
Based on a review of client records conducted during the on-site inspection on June 26, 2019, and based on staff interviews conducted during the inspection on June 26, 2019, the facility failed to notify the Department in writing within 3 business days of the death of a client by suicide. Client #6 was admitted for treatment on October 13, 2018. The client ' s discharge summary dated February 23, 2019, documented that the client committed suicide on January 4, 2019, but at the time of the on-site inspection the facility had not notified the Department of the client ' s suicide. These findings were reviewed with facility staff as part of the licensing process.
|
Plan of Correction
Facility Director will review the unusual incident reporting policy with all staff during scheduled meeting on 7/30/2019 to ensure every member of the team understands when an Unusual Incident report needs to be completed.
To ensure this citation does not occur again, during weekly clinical meetings, the facility director will review the reporting process of Unusual Incident Reports.
|
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 on a review of client records conducted during the on-site inspection on June 26, 2019, the facility failed to update client treatment plans at least once every 60 days in four of six applicable outpatient records.Client #1 ' s individualized treatment plan was dated January 2, 2019, but the client ' s treatment plan was not updated until March 21, 2019, and not again until May 28, 2019. Client #2 ' s individualized treatment plan was updated on January 14, 2019, but was not updated again until May 29, 2019. Client #3 ' s individualized treatment plan was dated February 8, 2019, but the client ' s treatment plan was not updated until April 12, 2019. Client #4 ' s individualized treatment plan was dated August 2, 2018, but the client ' s treatment plan was not updated until October 18, 2018. These findings were reviewed with facility staff as part of the licensing process.
|
Plan of Correction
Facility Director will hold a staff meeting on July 30th, 2019 to review policy and procedures surrounding updating individualized treatment plans at least once every 60 days.
Following the review during the staff meeting, Facility Director will monitor compliance through monthly open and closed chart audits.
If the counselor is not meeting the standard, supervision will be conducted and documented. |