INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia, Inc. People With Hope/Short-Term Program 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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704.9(b) LICENSURE Performance evaluation
704.9. Supervision of counselor assistant.
(b) Performance evaluation. The counselor assistant shall be given a written semiannual performance evaluation based upon measurable performance standards. If the individual does not meet the standards at the time of evaluation, the counselor assistant shall remain in this status until the supervised period set forth in subsection (c) is completed and a satisfactory rating is received from the counselor assistant's supervisor.
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Observations
Based on the review of personnel records and an interview with the facility director, the facility failed to document semiannual performance evaluations for counselor assistants in one of two personnel records.
The findings include:
On May 13, 2011, two personnel records identified as a counselor assistant were reviewed for documentation of semiannual performance evaluations. The facility did not document semiannual performance evaluations in personnel record # 9.
The documented performance evaluations for personnel # 9 were dated 1/14/11 and 2/21/11.
An interview with the facility director on May 18, 2011 confirmed the findings.
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Plan of Correction
Program Director has met with the clinical supervisor to review and train on the standard for semiannual performance evaluation of a counselor assistant. This semiannual evaluation will be based on measurable performance standards. If this individual does not meet the standards at the time of the evaluation, the counselor assistant shall remain in this status until a satisfactory rating is received from the counselor assistant's supervisor. Clinical Supervisor will be responsible for supervisory follow up and Division Director will be responsible for oversight. Full compliance will be met effective 06/17/11. |
709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on the review of client records and an interview with the facility director, the facility failed to comply with 4 Pa. Code relating to projects and coordinating bodies: disclosure of client-oriented information.
The findings include:
On May 18, 2011, ten client records were reviewed for documentation of informed and voluntary consent. The facility ' s consent to " Obtain " information forms permitted the facility to act in reliance on a client ' s verbal consent to release information. This is in violation of 709.28 (c)
c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(1)Name of the person, agency or organization to whom disclosure is made.
(2)Specific information disclosed.
(3)Purpose of disclosure.
(4)Dated signature of client or guardian.
(5)Dated signature of witness.
(6) Expiration date of the consent.
Client records # 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10 contained signed consent to obtain information forms that stated:
" I understand that my records are protected under the Federal Confidentiality Regulations and cannot be disclosed without my written or verbal consent unless otherwise provided for in the regulations. "
In client record # 1, this consent to obtain information form was signed by the client on 12/28/10.
In client record # 2, this consent to obtain information form was signed by the client on 1/24/11.
In client record # 3, this consent to obtain information form was signed by the client on 1/25/11 and 2/22/11.
In client record # 4, this consent to obtain information form was signed by the client on 2/14/11 and 3/2/11.
In client record # 5, this consent to obtain information form was signed by the client on 3/8/11.
In client record # 6, this consent to obtain information form was signed by the client on 3/15/11.
In client record # 7, this consent to obtain information form was signed by the client on 4/13/11.
In client record # 8, this consent to obtain information form was signed by the client on 3/31/11.
In client record # 9, this consent to obtain information form was signed by the client on 5/11/11.
In client record # 10, this consent to obtain information form was signed by the client on 5/5/11 and 5/17/11.
An interview with the facility director on May 18, 2011 confirmed the findings.
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Plan of Correction
Program Director has met with staff again and held training on confidentiality. The training focused on informed and voluntary consent for the obtaining of information. In addition forms have been changed to only state "can not be disclosed without my WRITTEN consent including where possible records # 1,2,3,4,5,6,7,8,9,10. Clinical supervisor will be responsible for supervisory follow up and Program Director will be responsible for oversight. Program will be in full compliance with this standard effective 06/17/2011. |
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 the review of client records and an interview with the facility director, the facility failed to document a physical examination within 7 days of admission in six of nine client records.
The findings include:
On May 18, 2011, nine client records requiring documentation of a physical examination were reviewed. The facility did not document physical examinations within 7 days of admission, as per facility policy, in client records # 1, 2, 3, 4, 7 and 10.
The facility ' s 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. Other exceptions are:
1.The client received a complete physical examination no longer than one month prior to admission; that the program staff can obtain the results in writing; and the nurse on duty is able to ascertain no noticeable medical problems. "
Client # 1 was admitted on 12/21/10. The physical exam for client # 1 was dated 1/13/11.
Client # 2 was admitted on 1/18/11. The physical exam for client # 2 was dated 2/9/11.
Client # 3 was admitted on 1/21/11. The physical exam for client # 3 was signed but not dated.
Client # 4 was admitted on 2/14/11. The physical exam for client # 4 was dated 3/9/11.
Client # 7 was admitted on 4/13/11. The physical exam for client # 7 was dated 4/21/11.
Client # 10 was admitted on 5/5/11. A physical exam was not documented at the time of review.
An interview with the facility director on May 18, 2011 confirmed the findings.
This is a repeat citation.
The facility was previously cited on November 18, 2009, June 11, 2009 and June 3, 2008 for failing to document physical examinations within 7 days of admission.
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Plan of Correction
Division Director met with the Physician to review and train on the standard for documentation of physical examination within 7 days of admission. A system has been put in place to make sure that physical examinations are completed and documented within the required time frame. Nurse Manager will be responsible for supervisory follow up and Divison Director will be responsible for ovesight. Full compliance will be met 06/17/2011. |
709.52(a)(2) LICENSURE Tx type & frequency
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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on the review of client records and an interview with the facility director, the facility failed to document treatment plans to include type and frequency of treatment and rehabilitation services in three of nine client records.
The findings include:
On May 18, 2011, treatment plans in nine client records were reviewed. The facility did not document treatment plans to include type and frequency of treatment and rehabilitation services in client records # 7, 9 and 10.
In client record # 7, the treatment plan documented on 3/18/11, did not include type and frequency of treatment and rehabilitation services.
In client record # 9, the treatment plan documented on 5/12/11, did not include type and frequency of treatment and rehabilitation services.
In client record # 10, the treatment plan documented on 5/9/11, did not include type and frequency of treatment and rehabilitation services.
This is a repeat citation.
The facility was previously cited on June 11, 2009 for failing to document treatment plans with type and frequency of treatment and rehabilitation services.
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Plan of Correction
All treatment files will include type and frequency of treatment in their treatment plans. This means that type will include either, individual/group/family therapy/health education, etc. Frequency will include, daily, 2-3 x weekly, once, ongoing, etc. The program director has conducted and will review monthly with clical staff the requirements for treatment plans. In addition the form has been changed to specifically identify "type and frequency". This standard is in place and full compliance will be bet effective 06/17/2011. Due to the fact that this has been a repeat citation in previous inspections this will be monitored closely. The clinical supervisor will be responsible for supervison for a period of not less than three months and on a weekly basis and ongoing thereafter. The program director will be responsible for oversight. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records and an interview with the facility director, the facility failed to document treatment plan updates to include an assessment of the client ' s progress, as per facility policy, in five of seven records.
The findings include:
On May 17, 2011, seven client records requiring treatment plan updates were reviewed, specifically, records # 1, 3, 4, 5, 6, 7 and 8. The treatment plan updates did not include an assessment of progress, as per facility policy, in client records #1, 3, 4, 5 and 8.
The facility's policy titled " Treatment Plan Reviews " states:
" The Counselor shall complete a treatment plan review and update 30 days after the date of the original individual treatment plan for residential, (and every 30 days thereafter), 14 days after the date of the original individual treatment plan for short-term (and every 14 days thereafter) and 60 days after for outpatient and every 60 days thereafter. This review shall include an assessment of the client's progress with the goals identified on the treatment plan along with a specific indication of how each goal has been impacted. Any goal or action step additions, revisions and deletions shall also be reflected. Goal and action step changes shall also be reflected on the treatment plan. The update shall be signed by the Counselor and submitted to the Clinical Supervisor for review and signature. "
In client record #1, the treatment plan updates documented on 1/6/11 and 3/11/11 did not include an assessment of progress.
In client record #3, the treatment plan updates documented on 2/24/11 and 3/24/11 did not include an assessment of progress.
In client record #4, the treatment plan updates documented on 3/16/11 and 4/16/11 did not include an assessment of progress.
In client record #5, the treatment plan update documented on 5/12/11 did not include an assessment of progress.
In client record #8, the treatment plan update documented on 5/4/11 did not include an assessment of progress.
This is a repeat citation.
The facility was previously cited on November 18, 2010, June 28, 2010, November 18, 2009 and June 11, 2009 for failing to document treatment plan updates to include an assessment of progress.
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Plan of Correction
The program director has conducted a training with all clinical staff on the policy and procedure for completing treatment plans and treatment plan updates again. This process includes documentation of an assessment of the client's progress with the goals identified on the initial treatment plan. The counselor shall complete a a treatment plan and review and update 30 days after the date of the original individual treatment plan. This review shall include an assessment of the client's progress with the goals identified on the initial treatment plan. This standard is in place and will be in full compliance by 06/17/2011. It will be monitored by the program director and clinical supervisor for a period of not less than three months and on a weekly basis and ongoing thereafter. Division director will be responsible for oversight. |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on the review of client records and an interview with the facility director, the facility failed to document follow-up information in three of three client records.
The findings include:
On May 18, 2011, three client records requiring documentation of follow-up information were reviewed. The facility did not document follow-up information, as per facility policy, in client records # 1, 2 and 3.
The facility ' s policy titled " FOLLOW UP INFORMATION " states:
" 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. "
Client # 1 was discharged on 3/18/11. An aftercare referral appointment was scheduled for 3/18/11, but follow-up information was not documented at the time of review on 5/18/11.
Client # 2 was discharged on 4/4/11. An aftercare referral appointment was not scheduled, but follow-up information was not documented at the time of review on 5/13/11.
Client # 3 was discharged on 4/13/11. An aftercare referral appointment was scheduled for 4/13/11, but follow-up information was not documented until 5/10/11.
An interview with the facility director on May 18, 2011 confirmed the findings.
This is a repeat citation.
The facility was previously cited on November 18, 2010 and June 28, 2010 for failing to document follow-up information.
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Plan of Correction
Program Director has met with clinical supervisor to review and train on the standards for documentation of follow-up information within one week from discharge. A follow-up log has been put in place as well as designated staff to complete documenation of follow-up. Clinical Supervisor will be responsible for supervisory follow-up and Program Director will be responsible for oversight. Full compliance will be met 06/17/2011. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of areas of noncompliance identified during this licensing inspection that had previously been cited, the facility failed to comply with prior plans of correction approved by the Department.
The findings include:
On May 18, 2011 the facility was again found to be out of compliance with the following standards:
1. 709.51(b)(5) - Intake and Admission: Physical Examinations.
This area of noncompliance was also identified during the licensing inspections conducted on November 18, 2009 (plan of correction submitted on 12/28/2009 and approved on 1/8/2010), June 11, 2009 (plan of correction submitted on 7/8/2009 and approved on 7/9/2009) and June 3, 2008 (plan of correction submitted on 7/14/2008 and approved on 7/18/2008).
2. 709.52(a)(2) - Treatment and Rehabilitation Services: Type and frequency of treatment and rehabilitation services.
This area of noncompliance was also identified during the licensing inspections conducted on June 11, 2009 (plan of correction submitted on 7/8/2009 and approved on 7/9/2009).
3. 709.52(b) - Treatment and Rehabilitation Services: Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
This area of noncompliance was also identified during the licensing inspections conducted on November 18, 2010 (plan of correction submitted on 12/20/2010 and approved on 12/23/2010), June 28, 2010 (plan of correction submitted on 8/19/2010 and approved on 8/21/2010), November 18, 2009 (plan of correction submitted on 12/28/2009 and approved on 12/31/2009) and June 11, 2009 (plan of correction submitted on 7/8/2009 and approved on 7/9/2009).
4. 709.53(a)(11) - Client Records: Follow-up information.
This area of noncompliance was also identified during the licensing inspections conducted on November 18, 2010 (plan of correction submitted on 12/20/2010 and approved on 12/23/2010) and June 28, 2010 (plan of correction submitted on 8/19/2010 and approved on 8/21/2010).
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Plan of Correction
1. Division Director met with the Physician to review and train on the standard for documentation of physical examination within 7 days of admission. A system has been put in place to ensure that physical examinations are completed and documented within the required time frame. Nurse Manager will be responsible for supervisory follow up and Division Director will be responsible for oversight. Full compliance will be met 06/17/11.
2. All treatment files will include type and frequency of treatment in their treatment plans. Clinical supervisor has conducted a training with clinical staff on documentation of type and frequency in a treatment plan according to standards. Clinical supervisor will be responsible for supervisory follow up and Program director will be responsible for oversight. Full compliance will be met 06/17/2011.
3. The Program Director has conducted a training with all clinical stff on the policy and procedure for completing treatment plans and treatment plan updates again. This process includes documentation of assessment of previously stated goals according to standards. Clinical supervisor will be responsible for supervisory follow up and program Director will be responsible for oversight. Full compliance will be met 06/17/11.
4. Program Director has met with Clinical Supervisor to review and train on the standards for documentation of follow up information within one week from discharge. A follow up log has been put in place as well as designated staff to complete documentation of follow up. Clinical supervisor will be responsible for supervisory follow up and Program Director will be responsible for oversight. Full compliance will be met 06/17/2011.
Due to the fact that these areas have been previously cited a plan to provide additional supervison and oversight has been implemented. These areas have been flagged to monitor and report on in monthly continued quality improvement meetings by the Program Director. These areas will required to be in full compliance in both active and in-active client charts. The Division Director will be responsible for oversight to enure that these areas remain in full compliance. |