INITIAL COMMENTS
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This report is a result of an on-site licensure provisional renewal inspection and complaint investigation conducted on November 3, 2015 - November 5, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Inc. West Chester 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, the facility failed to ensure that each counselor met the qualifications for the position in one of one personnel record reviewed.
The findings include:
One clinical personnel record for the position of counselor was reviewed on 11/5/2015. The facility failed to ensure that employee # 7 met the educational requirements for the position of counselor.
Employee # 7 was hired as a bachelor's level counselor on 8/28/2015. Employee # 7 did not meet the qualifications for the position of counselor as they did not have a bachelor's degree with an approved major.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation. The facility was previously cited for non-compliance with this standard during the 5/19/2015 and 4/30/2014 inspections.
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Plan of Correction
Corrective Action:
The Division Director, Program Director and Compliance Manager will ensure that at the time of hire each counselor meets the qualifications for the position for which they are hired.
The Program Director and Clinical Supervisor will ensure that all individuals performing the work of counselors receive a minimum of 25 hours of training per year. The Human Resources Manager will review all counselor training hours semi-annually to ensure compliance with this standard.
The Division Director, Program Director and Compliance Manager will assume clinical and supervisory monitoring responsibilities by December 14, 2015.
Persons Responsible:
Division Director, Program Director and Compliance Manager
Timeframe for Completion: December 14, 2015.
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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).
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Observations
Based on a review of personnel records, the facility failed to ensure that each counselor assistant was supervised by a full-time clinical supervisor or counselor in two of four personnel records reviewed.
The findings include:
Four clinical personnel records for the position of counselor assistant were reviewed on 11/5/2015. The facility failed to ensure that employees # 5 and 6 were supervised by a full-time clinical supervisor or counselor.
Counselor assistants # 5 and 6 were being supervised by the employee # 1. Employee # 1 is not a full-time clinical supervisor or counselor. Employee # 1 is the full-time facility director.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Corrective Action:
The Division Director and new Clinical Supervisor assumed responsibility to ensure that each counselor assistant was supervised by a full-time clinical supervisor or counselor. Prior to this date, the previous Program Director and Program Supervisor, who are no longer with the Program, were responsible for ensuring compliance in this area.
The current Division Director and new Clinical Supervisor will assume clinical and supervisory monitoring responsibilities as of December 14, 2015.
Persons Responsible:
Division Director, Clinical Supervisor
Time frame for Completion: December 14, 2015
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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of the facilities staff schedule work hours and the CPR certification cards, the facility failed to provide a sufficient number of staff persons trained in CPR during the project's hours of operation.
The findings include:
The CPR certification cards were reviewed on 10/29/2015 as part of the pre-submission review process. The facility is an inpatient facility that operates 24 hours a day and 7 days per week. The facility failed to ensure that there was at least one person certified in CPR working in the building at all times.
On 10/11/2015 between 7:45 AM - 11:00 AM there were two staff members present in the facility. Neither of the staff members present in the facility between 7:45 AM - 11:00 AM had a current certification in CPR.
On 10/18/2015 between 7:45 AM - 8:00 AM there was only one staff member present in the facility. The staff member present in the facility between 7:45 AM - 8:00 AM did not have a current certification in CPR.
On 10/25/2015 between 7:45 AM - 9:00 AM there was only one staff member present in the facility. The staff member present in the facility between 7:45 AM - 9:00 AM did not have a current certification in CPR.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director and Program/Clinical Supervisor will ensure that CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation in accord with Directive 704.11.
Clinical management staff will arrange for CPR Certification Training of all assign the Administrative Coordinator to monitor CPR certifications on monthly monitoring training grid. Staff will be scheduled for renewals prior to the expiration of their CPR certification.
Persons Responsible: Program Director, Program/Clinical Supervisor and Administrative Coordinator.
Timeframe: December 14, 2015; Training monitoring grid: monthly/ongoing
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704.12(a)(3)(i) LICENSURE NonHosp Rehab
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(3) Inpatient nonhospital treatment and rehabilitation (residential treatment and rehabilitation).
(i) Projects serving adult clients shall have one FTE counselor for every eight clients.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report form completed by the facility on 10/27/2015 and an interview with the facility director, the facility failed to ensure that client to staff ratio remained at or under 8:1.
The findings include:
The Staffing Requirements Facility Summary Report form completed by the facility was reviewed on 11/5/2015. Based on the total number of clinical staff hours per week for drug and alcohol clients and the standard work week of 35 hours, the facility exceeded the allowable maximum 8:1 client to staff ratio.
The client to staff ratio is determined by dividing the Full Time Equivalent (FTE) into the actual number of clients. The FTE is determined by dividing the number of hours devoted to the clients' treatment by the standard work week of 35 hours.
The number of hours per week devoted all clinical staff to client treatment, as reported by the facility on the Staffing Requirements Facility Summary Report, was 252 hours per week. The facility reported on the Staffing Requirements Facility Summary Report form a total of 59 active clients on 10/27/2015.
Ratio Calculation (252/35 = 7.2 FTE 59 clients/7.2 FTE = 9:1 ratio)
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Division Director, Program Director and Clinical Supervisor will ensure that in accord with 704.12, all Full-time equivalent (FTE) maximum client/staff and client/counselor ratios are 8:1 during primary care hours.
Appropriate clinical staff are being hired to care clinical services to ensure that a ratio of 8:1 is maintained.
Persons Responsible: Division Director Program Director and Clinical Supervisor.
Timeframe: January 25, 2016 |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection, the facility failed to ensure the facility grounds were in good repair.
The findings include:
The physical plant inspection occurred on 11/5/2015 at approximately 10:00 AM.
The back corner of the side of the building by fire escape in disrepair as there was a 1' x 3'' section deteriorated hole in the exterior wall.
The dresser across from bed #1 in room #5 in the men's unit was in disrepair that the sliding mechanism for three of the drawers were broken and the drawers were collapsed on top of one another.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Maintenance Department has scheduled the identified needed repair to the building exterior and grounds, namely the back corner of the side of the building by the fire escape where there was reportedly a "1 X 3" section deteriorated hole in the exterior wall.
This project requires that corrections be implemented in stages so that the grounds are kept in good repair in a clean, safe and sanitary manner for the safety and well-being of residents, employees and visitors. the final portion of this repair will be completed by 02/28/16.
The dresser across from bed #1 in room #5 in the Men's Dorm was in disrepair. The dresser was removed by the Maintenance Department on the day of the observation, 11/05/15. The dresser has been replaced with an appropriate dresser.
To ensure that this does not recur, designated staff will inspect the condition of the housing unit furniture and the facility grounds and report any concerns on the Weekly Safety/Sanitation Report. This report is submitted to and reviewed by the Management team who will forward any concerns to the Maintenance Department and/or arrange for replacement in conjunction with agency/facility policy and procedure.
Persons Responsible: Program Director, Clinical/Program Supervisor, House Manager and Maintenance Department.
Timeframe: Dresser Removal and Replacement completed 11/05/15; Building Repairs-02/28/16
Weekly Reports- ongoing |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on observation during a physical plant inspection, the facility failed to ensure privacy so that counseling sessions could not be seen or heard outside of the counseling room.
The findings include:
A physical plant inspection was conducted on 11/5/2015 at approximately 10:00 AM.
Counselor # 7 was conducting a one-on-one session with a client in the counseling office located next to the conference room in the lower level of the building. The door to the counseling office was wide open at the time of the one-on-one session. The counselor's questions and the client's personal responses were clearly heard from the conference room across hall by the licensing specialist completing this report.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director, Clinical Supervisor will ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
Division Director, Program Supervisor provided Counselor # 7 appropriate supervision and coaching, in addition to all program clinical staff, regarding the responsibility to ensure appropriate privacy so that counseling sessions cannot be seen or heard outside the counseling room. This will be reviewed in upcoming Record Keeping Training on January 15, 2016. Counselor # 7 has been scheduled for Confidentiality Training on 02/24/16.
Additionally, counselors will submit weekly schedules of individual sessions to Program/Clinical Supervisor. Management staff will then conduct random tours during those individual session hours to ensure that this does not reoccur. The topic of Confidentiality will also be discussed in staff meetings for 6 months starting 02/2016 and then thereafter bi-monthly for the remainder of 2016. Thereafter, this will continue to be an ongoing training issue with all clinical staff.
Persons Responsible: Division Director, Program Director, Program/ Clinical Supervisor, Counselors
Timeframe: December 15, 2015 & January 15,2016; Staff Meetings: 6 months (ending August 2016) & bi-monthly. |
705.5 (a) (1) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(a) In each residential facility bedroom, each resident shall have the following:
(1) A bed with solid foundation and fire retardant mattress in good repair.
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Observations
Based on observation during a physical plant inspection, the facility failed to ensure that each bedroom contained a mattress in good repair.
The findings include:
A physical plant inspection was conducted on 11/5/2015 at approximately 10:00 AM.
The mattress on bed #39 in room 14 in the men's unit had two significant tears in the side of the mattress. The tears were 5'' and 3'' in length.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director arranged for the Maintenance Department to remove the temporary mattress that was on bed #39 in room 14 in the men's unit, which was reportedly damaged during a bed bug inspection. The mattress had two (2) significant tears in the side of the mattress that were reportedly "5'' and 3'' in length."
This mattress was removed discarded on 11/05/15 to ensure that in each facility bedroom, each resident shall have the following: (1) A bed with solid foundation and fire retardant mattress in good repair.
Operational staff will complete daily inspections, in conjunction with bed bug inspections to ensure that all mattresses remain in good repair.The findings will be recorded on the designated form. The form will be submitted to the Management team whom will address any issues. In the event that replacement is needed, the appropriate measures will be taken to replace any mattress that is not in good repair.
Persons Responsible: The Program Director, Program/Clinical Supervisor and House Managers.
Timeframe: 11/05/15; Inspections: Ongoing and daily |
705.7 (b) (6) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(6) Store all food items off the floor.
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Observations
Based on observation during a physical plant inspection, the facility failed to ensure that all food items were stored off the floor.
The findings include:
A physical plant inspection was conducted on 11/5/2015 at approximately 10:00 AM.
There was a large dark grey trash bag filled with frozen vegetable greens that were being stored on the floor in the middle of freezer #1. Furthermore, there were two shucked ears of corn resting on the floor underneath the metal shelving unit in freezer #1.
There were at least five onions resting on the floor just outside of the cold storage units.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Food Services Supervisor will ensure that the all food items are stored off the floor.
The Food Services Supervisor removed the large trash bag filled with frozen vegetable greens that had fallen to the floor from the shelf in freezer #1. Additionally, the two ears of corn that had also fallen and the five onions that "were resting on the floor" were also removed on 11/05/15 and discarded in the trash. The remaining items (not resting on the floor) were rearranged in the designated area on the shelf to ensure that they would not fall to the floor. Additionally, all uncovered and unbagged food items were discarded in the trash.
The Food Services Supervisor will conduct daily inspections to ensure that no food items have fallen to the floor and that they are stored properly. The Program Director will ensure that these inspections take place.
Persons Responsible: Program Director and Food Services Supervisor
Timeframe: food discarded: 11/05/15; Inspections: daily and ongoing |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in two of two client records.
The findings include:
Two client records requiring written notification to the client of the facility's decision to involuntarily terminate the client's treatment were reviewed on 11/3/2015 - 11/5/2015. The facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the facility in client records # 9 and 10.
Client # 9 was admitted into treatment on 7/17/2015 and was involuntarily terminated from the facility on 8/31/2015. There was no documentation of written notification to the client of the facility's decision to involuntarily terminate the client's treatment as of the on-site inspection.
Client # 10 was admitted into treatment on 7/21/2015 and was involuntarily terminated from the facility on 9/11/2015. There was no documentation of written notification to the client of the facility's decision to involuntarily terminate the client's treatment as of the on-site inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Termination letters were developed and sent for client # 9 and client #10 on November 11, 2015 by Clinical Supervisor.
The Gaudenzia West Chester House Program will notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project.
On January 15, 2016 a Record-Keeping training will be facilitated to review the Notification of Termination DOH DDAP Policy 709.33(a).
All involuntary terminations will be reviewed and monitored by Program Management during monthly Continuous Quality Improvement (CQI) meetings to ensure compliance.
Persons Responsible: Program Director, Clinical/Program Supervisor
Timeframe for Completion: November 11, 2015; January 15, 2016 |
709.51(b)(3)(ii) LICENSURE Drug & Alcohol History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on the review of client records, the facility failed to document a drug or alcohol history upon intake in three of ten client records reviewed.
The findings include:
Ten client records requiring documentation of a drug or alcohol history were reviewed on 11/3/2015 - 11/5/2015. The facility failed to document a drug or alcohol history for client records # 7, 8 and 10.
Client # 7 was admitted to treatment on 9/18/2015 and discharged on 9/28/2015. A drug or alcohol history was not documented in the client's record.
Client # 8 was admitted to treatment on 9/4/2015 and discharged on 9/26/2015. A drug or alcohol history was not documented in the client's record.
Client # 10 was admitted to treatment on 7/21/2015 and discharged on 9/11/2015. A drug or alcohol history was not documented in the client's record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A record-keeping training will be facilitated on January 15, 2016 to ensure that client records requiring documentation of drug and/or alcohol history is documented as required by the Division of Drug and Alcohol Licensure per DOH Policy 709.51(b)(3)(ii) Intake and admissions procedures.
All drug and alcohol histories will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings.
Persons Responsible:
Division Director, Program Director and Clinical Supervisor
Timeframe for Completion: January 15, 2016 |
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 complete a personal history upon intake in three of ten client records reviewed.
The findings include:
Ten client records requiring documentation of a personal history were reviewed on 11/3/2015 - 11/5/2015. The facility failed to document a personal history for client records # 7, 8 and 10.
Client # 7 was admitted to treatment on 9/18/2015 and discharged on 9/28/2015. A personal history was not documented in the client's record.
Client # 8 was admitted to treatment on 9/4/2015 and discharged on 9/26/2015. A personal history was not documented in the client's record.
Client # 10 was admitted to treatment on 7/21/2015 and discharged on 9/11/2015. A personal history was not documented in the client's record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
A record-keeping training will be facilitated on January 15, 2015 to review the required documentation for Intake and Admission procedures. This will include the requirement of histories which include personal history.
All Intake and Admission and monitored during monthly Continuous Quality Improvement (CQI) meetings by the Program Director and Clinical Supervisor.
Persons Responsible:
Division Director, Program Director and Clinical Supervisor
Timeframe for Completion: January 15, 2016. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to complete a psychosocial evaluation upon intake in five of ten client records reviewed.
The findings include:
Ten client records requiring documentation of psychosocial evaluations were reviewed on 11/3/2015 - 11/5/2015. The facility failed to complete a psychosocial evaluation in client records # 1, 6, 7, 8 and 10.
Client # 1 was admitted to treatment on 9/9/2015. A psychosocial evaluation was not documented in the client's record.
Client # 6 was admitted to treatment on 9/19/2015 and discharged on 9/30/2015. A psychosocial evaluation was not documented in the client's record.
Client # 7 was admitted to treatment on 9/18/2015 and discharged on 9/28/2015. A psychosocial evaluation was not documented in the client's record.
Client # 8 was admitted to treatment on 9/4/2015 and discharged on 9/26/2015. A psychosocial evaluation was not documented in the client's record.
Client # 10 was admitted to treatment on 7/21/2015 and discharged on 9/11/2015. A psychosocial evaluation was not documented in the client's record.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation. The facility was previously cited for non-compliance with this standard during the 5/19/2015 inspection.
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Plan of Correction
Plan of Correction:
Client #1's Psycho-social was completed by Clinical Supervisor on 11/06/15. Client #1 discharged on 11/09/15.
Additionally, a Record-Keeping training will be facilitated on January 15, 2016 to review the required documentation for Intake and Admission procedures. This will include the requirement of Psycho-social evaluations.
All Intake and Admission documentation and procedures will be monitored during monthly Continuous Quality Improvement (CQI) meetings by the Program Director and Clinical Supervisor.
Persons Responsible:
Division Director, Program Director and Clinical Supervisor
Timeframe for Completion: November 6, 2015; Training: January 15, 2016. |
709.51(b)(7) LICENSURE Preliminary Tx. Plan.
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on the review of client records, the facility failed to complete a preliminary treatment and rehabilitation plan upon intake in three of ten client records reviewed.
The findings include:
Ten client records requiring documentation of a preliminary treatment and rehabilitation plan were reviewed on 11/3/2015 - 11/5/2015. The facility failed to complete a preliminary treatment and rehabilitation plan in client records # 6, 7 and 8.
Client # 6 was admitted to treatment on 9/19/2015 and discharged on 9/30/2015. A preliminary treatment and rehabilitation plan was not documented in the client's record.
Client # 7 was admitted to treatment on 9/18/2015 and discharged on 9/28/2015. A preliminary treatment and rehabilitation plan was not documented in the client's record.
Client # 8 was admitted to treatment on 9/4/2015 and discharged on 9/26/2015. A preliminary treatment and rehabilitation plan was not documented in the client's record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
A record-keeping training will be facilitated on January 15, 2015 to review the required documentation for preliminary treatment plans.
The preliminary treatment plan will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings by the Program Director and Program/Clinical Supervisor.
Persons Responsible:
Program Director and Program/Clinical Supervisor
Timeframe for Completion: January 15, 2016; CQI: monthly and ongoing |
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 a review of client records, the facility failed to maintain documentation that individual treatment and rehabilitation plans were developed with the client in three of seven client records reviewed.
The findings include:
Nine client records requiring documentation that individual treatment and rehabilitation plans were developed with the client were reviewed on 11/3/2015 - 11/5/2015. There was no documentation that individual treatment plans were developed with the client in client records # 4, 9 and 10.
Client # 4 was admitted to treatment on 8/27/2015. There was no documentation that the client's individual treatment and rehabilitation plan dated 9/27/2015 was completed with the client.
Client # 9 was admitted to treatment on 7/17/2015 and discharged on 8/31/2015. There was no documentation that the client's individual treatment and rehabilitation plan dated 8/22/2015 was completed with the client.
Client # 10 was admitted to treatment on 7/21/2015 and discharged on 9/11/2015. There was no documentation that the client's individual treatment and rehabilitation plans dated 8/27/2015 and 7/25/2015 was completed with the client.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation. The facility was previously cited for non-compliance with this standard during the 5/19/2015 inspection.
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Plan of Correction
Plan of Correction:
A record-keeping training will be facilitated on January 15, 2015 to review the November 11, 2015 to review the required documentation for individual treatment and rehabilitation plans.
The training will also include the requirement that these plans be developed with the client. All clients will be required to sign each treatment plan, in which the client affirms (as stated above the signature line)that " I have developed this treatment plan with the help of my counselor". The client will also initial the area which indicates that they have been offered a copy.
All treatment planning documentation will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings by the Program Director and Program/Clinical Supervisor who will ensure that the proper client signatures are on the treatment plan.
Persons Responsible:
Program Director and Program/Clinical Supervisor, Counselors
Timeframe for Completion: January 15, 2016. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on the review of client records, the project failed to ensure that counseling services were provided according to the individual treatment plan in five of seven client records reviewed.
The findings include:
Seven client records were reviewed for counseling services on 11/3/2015 - 11/5/2015. The project failed to ensure that clients received counseling services according to the client's individual treatment plan in client records # 1, 2, 3, 4, and 10.
Client # 1 was admitted on 9/9/2015. The client's contained a treatment plans dated 10/20/2015 and 10/12/2015 that identified the counseling services to be provided as three different types of group therapy (Static Group, Encounter Group and Relapse Prevention Group) weekly. The record did not contain documentation of any of these group therapy sessions.
Client # 2 was admitted on 8/25/2015. The client's record contained a treatment plan dated 9/25/2015 that identified the counseling services to be provided as three different types of group therapy (Static Group, Encounter Group and Relapse Prevention Group) weekly and individual therapy weekly. The record did not contain documentation of any group or individual sessions in October 2015.
Client # 3 was admitted on 9/4/2015. The client's record contained a treatment plan dated 9/6/2015 that identified the counseling services to be provided as three different types of group therapy (Static Group, Encounter Group and Relapse Prevention Group) twice a week. The record did not contain documentation of any Static Groups and Encounter Groups in September 2015.
Client # 4 was admitted on 8/27/2015. The client's record contained treatment plans dated 9/27/2015 and 8/27/2015 that identified the counseling services to be provided as three different types of group therapy (Static Group, Encounter Group and Relapse Prevention Group) weekly and individual therapy weekly. The record did not contain documentation of any group therapy in October 2015. Furthermore, the record contained documentation of only one individual therapy session in September 2015 that occurred on 9/3/2015.
Client # 10 was admitted on 7/21/2015 and discharged on 9/11/2015. The client's record contained treatment plans dated 8/27/2015 and 7/25/2015 that identified the counseling services to be provided as three different types of group therapy (Static Group, Encounter Group and Relapse Prevention Group) weekly. The record did not contain documentation of any group therapy in August 2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A record-keeping training will be facilitated on January 15, 2016 to ensure that Counseling Services are provided according to the individual treatment and rehabilitative plans as required by the Division of Drug and Alcohol Licensure per DOH Policy 709.52 (c) Provision of Counseling Services.
All treatment planning documentation will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings by the Program Director and Clinical Supervisor.
Persons Responsible:
Division Director and Clinical Supervisor
Timeframe for Completion: January 15, 2016 |
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 ensure that a complete record was documented in six of ten client records reviewed.
The findings include:
Ten client records requiring documentation of a complete client record were reviewed on 11/3/2015 - 11/5/2015. The facility failed to document a complete record in client records # 2, 3, 4, 5, 8 and 9.
Client # 2 was admitted on 8/25/2015 and was still an active client at the time of the inspection. There was no documentation of a record of service for August 2015 - November 2015.
Client # 3 was admitted on 9/4/2015 and was still an active client at the time of the inspection. The client's record of service for October 2015 did not list the duration of the individual sessions on 10/2/2015, 10/9/2015, 10/16/2015, 10/23/2015 and 10/30/2015. Furthermore, the progress notes for the group sessions that the client attended on 9/2/2015, 9/9/2015, 9/16/2015, 9/23/2015 and 9/30/2015 did not indicate the client's participation in the group sessions.
Client # 4 was admitted on 8/27/2015 and was still an active client at the time of the inspection. There was no documentation of a record of service for August 2015 - November 2015. Furthermore, the progress notes for the group sessions that the client attended on 9/2/2015, 9/9/2015, 9/16/2015, 9/23/2015 and 9/30/2015 did not indicate the client's participation in the group sessions.
Client # 5 was admitted on 9/11/2015 and was still an active client at the time of the inspection. The client's record of service for October 2015 did not include the individual sessions that the client attended on 10/2/2015, 10/9/2015 and 10/16/2015. Furthermore, there were no progress notes documented for the individual sessions that the client attended on 9/18/2015, 9/24/2015, 9/28/2015, 10/1/2015 and 10/5/2015.
Client # 8 was admitted on 9/4/2015 and discharged on 9/26/2015. There was no documentation of a record of service for September 2015. Furthermore, there were no progress notes documented in the clients record.
Client # 9 was admitted on 7/17/2015 and discharged on 8/31/2015. The progress notes for the group sessions that the client attended on 7/21/2015, 7/29/2015 and 8/6/2015 did not indicate the client's participation in the group sessions.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation. The facility was previously cited for non-compliance with this standard during the 5/19/2015 inspection.
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Plan of Correction
Plan of Correction:
Accurate and updated Records of Service were completed by Clinical Supervisor for clients #2, 3, 4, 5 and 8 on November 11, 2015.
A record-keeping training will be facilitated on January 15, 2016 to include the Record of Service, Individual and Group Progress Notes as required by the Division of Drug and Alcohol Licensure per DOH Policy
709.53(a): Complete Client Record.
All treatment planning documentation will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings by the Program Director and Program/Clinical Supervisor.
Persons Responsible: Program Director, Program/Clinical Supervisor and Counselors.
Timeframe for Completion: November 11, 2015; January 15, 2016 |