INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 22, 2012 to May 23, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia, Inc. Outreach 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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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to document an individual training plan in accordance with facility policy in one of three records.
The findings include:
The project policy states: "In January of each year, the Program Director, in conjunction with the Supervisor, will conduct needs assessments, via individual training plan forms for all employees, to determine what topics and areas of training should be provided during the coming year."
On May 9, 2012, employee # 1's personnel record was reviewed. The project failed to develop an individual training plan annually in accordance with policy.
Employee # 1 has been the Project Director since 1988. Per policy, training plans will be conducted in January of each year. The facility failed to document an individual training plan in January for employee # 1.
The findings were reviewed with the human resources staff.
This is a repeat citation. The Project was previously cited for noncompliance with this standard during the 2011 licensure inspection.
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Plan of Correction
The training Department will ensure that an individual training plan is developed and documented for all employees within required timeframes. A reminder of the January 31st deadline for completion will be forwarded to all Managers during the 1st week of December. In addition, the Training Department will coordinate with the Executive Assistant to ensure that development of an Individual Training Plan for the Project Director is a specific agenda item during the Project Director's meeting with the Chairman of the Board during the month of December. A current, signed Individual Training Plan is presently in the Project Director's file. Individual Training Plans will be completed for all employees by January 31st, 2013 as per our policy. |
704.11(e)(2) LICENSURE Annual Trng Req-Clin Sup
704.11. Staff development program.
(e) Training requirements for clinical supervisors.
(2) Each clinical supervisor shall complete at least 12 clock hours of training annually in areas such as:
(i) Supervision and evaluation.
(ii) Counseling techniques.
(iii) Substance abuse trends and treatment methodologies in the field of addiction.
(iv) Confidentiality.
(v) Codependency/Adult Children of Alcoholics (ACOA) issues.
(vi) Ethics.
(vii) Interaction of addiction and mental illness.
(viii) Cultural awareness.
(ix) Sexual harassment.
(x) Developmental psychology.
(xi) Relapse prevention.
(xii) Disease of addiction.
(xiii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to ensure that each clinical supervisor completed 12 clock hours of required training.
The findings include:
On May 7, 2012 through May 9, 2012, two personnel records requiring documentation of 12 clock hours of training were reviewed. The facility failed to provide documentation of 12 clock hours of training in one of three personnel records reviewed, specifically, personnel record # 4.
Employee # 4, a clinical supervisor and counselor, was hired on August 31, 2010. The facility's training year is from January 1, 2011 to December 31, 2011. Employee # 4's personnel record only had documentation of 4 clock hours of training for the January 1, 2011 to December 31, 2011 training year as of May 9, 2012.
The findings were reviewed with the human resources staff.
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Plan of Correction
According to Gaudenzia policy Clinical Supervisor is require to complete 12 clock hours of training yearly. Moving forward employee number 4 will be schedule for the 12 clock hours of training that is required annually. All suppervisors will be required to provide documented trainings to the Program Director during the weekly administrative/managers meetings. The Program Director (Jacqueline Garland)will be responsible to ensure that the Clinical Supervisor has been schedule and has attended the trainings as required annually. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to ensure that each counselor completed 25 clock hours of required training.
The findings include:
On May 7, 2012 through May 9, 2012, three personnel records requiring documentation of 25 clock hours of training were reviewed. The facility failed to provide documentation of 25 clock hours of training in two of three personnel records reviewed, specifically, personnel records # 4 and 8.
Employee # 4, a clinical supervisor and counselor, was hired on August 31, 2010. The facility's training year is from January 1, 2011 to December 31, 2011. Employee # 4's personnel record only had documentation of 4 clock hours of training for the January 1, 2011 to December 31, 2011 training year as of May 9, 2012.
Employee # 8, a counselor, was hired for her current position on September 8, 2008. The facility's training year is from January 1, 2011 to December 31, 2011. Employee # 8's personnel record only had documentation of 24 clock hours of training for the January 1, 2011 to December 31, 2011 training year as of May 9, 2012.
The findings were reviewed with the human resources staff.
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Plan of Correction
Moving forward any Supervisor(s) carrying a caseload and acting in counselor position will meet the required 25 clock hours of training yearly. Employee # 4 will complete the required 25 clock hours of training annually for June 18, 2012 through December 31, 2012. Supervisors will schedule trainings annually for all clinical staff & monitor by management team (Supervisor & Program Director). All staff will provide documentation of trainings attended and forward to the Program Director during the weekly administrative/supervisory meetings. To ensure all trainings are scheduled, attended, and documented along with the feedback forms within the require timeframes to ensure compliance with this regulation. Copies of certificates will be archived in binders. Program Director (Jacqueline Garland) will be responsible to assure that all trainings are attended by clinical staff & supervisor(s) annually. |
704.12(a)(6) LICENSURE OutPatient Caseload
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.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) form completed by the facility on May 21, 2012, the facility failed to ensure that staff caseloads remained at or under 35:1 for three out of 10 staff reviewed.
The findings include:
On May 22, 2012 and May 23, 2012, the SRFSR form completed by the facility was reviewed. The form listed three clinical supervisors, six counselors, and one counselor assistant as the clinical staff. The facility documented three clinical supervisors, five counselors, and one counselor assistant as having a caseload, employees # 3, 4, 5, 6, 7, 8, 10, 11, and 12.
Employee # 3 had 6 clients and a caseload of 30/1; employee # 4 had 2 clients and a caseload of 16:1, employee # 5 had 31 clients and a caseload of 31:1; employee # 6 had 21 clients and a caseload of 21:1; employee # 7 had 26 clients and a caseload of 26:1; employee # 8 had 27 clients and a caseload of 27:1; employee # 10 had 31 clients and a caseload of 37:1; employee # 11 had 28 clients and a caseload of 28: 1; employee # 12 had 36 clients and a caseload of 36:1.
The facility's standard work week, as reported by the facility on the SRFSR form, was 40 hours per week.
Based on the total number of hours per week that the facility reported the employees devoted to their clients, the total number of hours in the facility's standard work week (40), and the total number of clients assigned to the following employees on May 22, 2012, employees # 10 and 12 exceeded the allowable maximum 35: 1 caseload.
The actual client caseload 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 client's treatment by the facility ' s standard workweek.
The number of hours per week devoted by Employee # 10 to client treatment, as report by the facility on the SRFSR form, was 34 hours per week. The facility reported on the SRFSR form that employee # 10 had 31 active clients on May 22, 2012.
Employee # 10 (34/40 = 0.85 FTE 31 clients/0.85 FTE = 37: 1 caseload)
The number of hours per week devoted by Employee # 12 to client treatment, as report by the facility on the SRFSR form, was 40 hours per week. The facility reported on the SRFSR form that employee # 12 had 36 active clients on May 22, 2012.
Employee # 12 (40/40 = 1 FTE 36 clients/1 FTE = 36: 1 caseload)
The findings were confirmed during an interview with the facility director on May 23, 2012 at approximately 3:00 P.M.
This is a repeat citation. The facility was cited on June 2, 2011 for noncompliance with this standard.
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Plan of Correction
Moving forward the Program Director/Supervisor(s) will monitor the staff ratio of 35:1 individual (client) for each counselor providing services. During the development of the Staff Requirements Facility Summary Report (SRFSR) it will indicate accurate services being provided by each counselor. Program Director will ensure that staff caseloads remain at or under 35:1 ratio. |
705.27 (4) (i) LICENSURE General safety and emergency procedures.
705.27. General safety and emergency procedures.
The nonresidential facility shall:
(4) Provide written procedures for staff and clients to follow in case of an emergency which shall include provisions for:
(i) The evacuation and transfer of clients and staff to a safe location.
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Observations
Based on a review of the facility's written procedures for staff and clients to follow in case of an emergency, the facility failed to provide written procedures for staff and clients to follow in case of an emergency for the evacuation and transfer of clients to a specific safe location for internal disasters for the facility's location.
The findings include:
The written procedures for staff and clients to follow in case of an emergency were reviewed on May 22, 2012 and May 23, 2012. The policy in the manual addresses external disasters for the facility's location and internal disasters for the project in general. However, the policy does not give a specific safe location for internal disasters for the facility's location.
The findings were confirmed during an interview with the facility director on May 23, 2012 at approximately 3:00 P.M.
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Plan of Correction
A written proceedure for internal disasters will be developed by the Program Director which will be discussed during the administrative meetings quarterly. The Program Director will be responsible for training the clinical and administrative staff regrading the written safety procedures quarterly. The written internal disaster procedures will indicate a specific safe loctaion for individuals (clients) & staff to position themselves in case of a disaster that cause for immediate evacuation from that specific location at Gaudenzia Outreach I Program. Moving forward the Program Director will be held responsible to assure that the new written procedure for the internal distaters remain in place at the facility. |
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.
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Observations
Based on a review of personnel records, the facility failed to instruct staff in the use of the fire extinguisher upon staff employment.
The findings include:
On May 7, 2012, May 9, 2012 and May 23, 2012,a total of three personnel records requiring documentation of fire extinguisher training were reviewed. The facility failed to ensure that they instructed staff in the use of fire extinguisher upon staff employment in three of three records reviewed, specifically, personnel records # 5, 6, and 7.
Employee # 5, a counselor, was hired on December 19, 2011. Employee # 5 was due to complete fire extinguisher training upon employment. However, employee # 5 did not complete fire extinguisher training until March 27, 2012.
Employee # 6, a counselor, was hired on August 22, 2011. Employee # 6 was due to complete fire extinguisher training upon employment. However, employee # 6 did not complete fire extinguisher training until March 27, 2012.
Employee # 7, a counselor assistant, was hired on June 21, 2011. Employee # 7 was due to complete fire extinguisher training upon employment. However, employee # 7 did not complete fire extinguisher training until March 27, 2012.
The findings were confirmed during an interview with the facility director on May 23, 2012 at approximately 3:00 P.M.
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Plan of Correction
Moving forward, Program/Clinical Supervisor will train/instruct all new staff on the use of fire extinguishers within the first week of employment. Program Director will ensure that the Supervisor(s) has provide new staff within the first week of employment the training of fire extingusher and documented that the training occurred and attach to the staff employment file. |
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.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies.
The findings include:
On May 7, 2012, May 9, 2012, and May 23, 2012, a total of three personnel records requiring documentation that all personnel on all shifts had been trained to perform assigned tasks during emergencies were reviewed. The facility did not ensure that all personnel on all shifts completed emergency training upon employment at the facility in three of three personnel records reviewed, specifically, personnel records # 5, 6, and 7.
Employee # 5, a counselor currently working at the facility, was hired on December 9, 2011. Employee # 5 was due to complete emergency training prior to working any shifts at the facility. However, employee # 5 did not complete emergency training until May 27, 2012.
Employee # 6, a counselor currently working at the facility, was hired on August 22, 2011. Employee # 6 was due to complete emergency training prior to working any shifts at the facility. However, employee # 6 did not complete emergency training until May 27, 2012.
Employee # 7, a counselor assistant currently working at the facility, was hired on June 21, 2011. Employee # 7 was due to complete emergency training prior to working any shifts at the facility. However, employee # 7 did not complete emergency training until May 27, 2012.
The findings were confirmed during an interview with the facility director on May 23, 2012 at approximately 3:00 P.M.
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Plan of Correction
Going forward the Program Director/Supervisor(s) will ensure that all personnel that is employed by Gaudenzia on all shifts complete the require training needed when perfoming tasks during an emergency. The training will be documented upon completion and attach to the personnel file of each employee that completed the require training. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill records, the facility failed to prepare and document alternate exit routes to be used during fire drills.
The findings include:
Fire drill records were reviewed on May 22, 2012. The records were reviewed from the period covering January 2012 to April 2012. The facility had documented the same exit routes, front exit and back exit, in four of four months reviewed, specifically, January 11, 2012; February 17, 2012; March 20, 2012; and April 19, 2012.
The findings were confirmed during an interview with the facility director on May 22, 2012 at approximately 11:00 A.M.
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Plan of Correction
Moving forward, Program Director will review with staff on June 12, 2012 the procedures for fire drills and alternate exits that will be utilized when conducting a fire drill. After each fire drill, the Program Director will ensure that the Program and Clinical Supervisors document on the evacuation forms which specific exits were used during the fire drill. The Supervisors will be responsible for ensuring the use of specific alternate exits which will be documented on the fire drill log to indicate the exits used during the fire drill while evacuating the building (e.g front exit to rear of building). |
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.
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Observations
Based upon a review of the project's Policy & Procedure (P&P) Manual, the project failed to adopt consistent policies for individualized treatment and rehabilitation plans. The facility had policies for treatment plans that were contradictory.
The findings include:
The P&P Manual was reviewed from May 1 - 2, 2012.
The policy titled, "Intake Process/Paperwork" Treatment Plan included the following language:
"The individualized treatment plan shall be completed, approved and signed by the Counselor, Clinical Supervisor and Medical Director(when applicable) within 3-5 client days residential..."
The policy titled, "Individual Treatment Plan" Individual Treatment and Rehabilitation Plan included the following language:
"Completion of the treatment plan will be noted in the counselor's progress note for that day of service, within 3 days of admission (residential)..."
The first policy allows five days to complete the individualized treatment plan while the second policy stipulates it must be completed within three days.
Regarding outpatient facilities, the policy titled, "Individual Treatment Plan" Individual Treatment and Rehabilitation Plan included the following language:
"An individual treatment and rehabilitation plan will be developed with each client after the completion of the client's psychosocial evaluation."
The policy titled, "Intake Process/Paperwork" Treatment Plan included the following language:
"Based on the psychosocial assessment, the Counselor shall formulate an individualized treatment plan ..."The individualized treatment plan shall be completed, approved and signed by the Counselor, Clinical Supervisor and Medical Director (when applicable) ... by the second or third counseling outpatient appointment....."
The policy titled, "Intake Process/Paperwork" Psychosocial Assessment stated:
Upon completion of the psychosocial histories...The assessment shall be submitted promptly ... to the Clinical Supervisor for review and signature ... within 3 individual sessions for outpatient.
The policy titled, "Individual Treatment Plan" Individual Treatment and Rehabilitation Plan included the following language:
"Completion of the treatment plan will be noted in the counselor's progress note for that day of service,... by the third session (outpatient)..."
Each policy relating to the completion of the treatment plans for outpatient contained statements that require the treatment plan be completed in three sessions (regardless of being individual or group) while there are other statements that would indicate that the treatment plan would not be required or allowed to be completed until the third individual session based on the completion of the psychosocial assessment.
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Plan of Correction
The revelant policies in the Gaudenzia Policy and procedure Manual will be revised by the Quality Improvement Director to ensure consistency and clarity, and to meet all relevant State, Accreditation, and Funding requirements. Changes to these policies will be reviewed and approved by the Board of Directors. These changes will be reviewed with clinicians at each facility's staff meetings by the Program Director and/or Program/Clinical Supervisors in order to ensure full understanding and ongoing compliance. Program/Clinical Supervisors will monitor timely completion of Initial Treatment Plans as part of regular clinical chart reviews, and the findings of these reviews will be discussed in regular clinical supervision as well as staff meetings and monthly CQI analysis. These policies will be revised and approved by July 31, 2012. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based upon the review of Administrative documentation, the project failed to have an independent annual audit of financial activities associated with the project's drug/alcohol abuse services completed upon conclusion of the fiscal year.
The findings include:
Licensing Staff conducted an Administrative Review from May 7 - 9, 2012.
Administrative documentation specified that the fiscal year runs from July 1 to June 30. However, the project's annual fiscal audit was late as it was completed February 20, 2012.
The findings were reviewed during the exit interview for the Administrative Review and were not disputed.
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Plan of Correction
At the most recent Audit Committee meeting, the necessity that all future financial audits must be completed within required timeframes was reinforced with the external independent public accountant. These timeframes were acknowledged by the independent public accountant and recorded in the meeting minutes. The Director of Finance and Accounting will maintain oversight throughout the auditing process to ensure completion in a timely manner. The Financial audit for Fiscal Year 2011-2012 will be completed within 6 months after the June 30th close of Gaudenzia's fiscal year (by December 31, 2012) as per Chapter 709.25(a). |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation in accordance with their policy and procedures.
The findings include:
The facility's policy titled: "Intake Process/Paperwork," states:
"Upon completion of the psychosocial histories, the Counselor will write a narrative psychosocial assessment prior to the next scheduled individual counseling session. The assignment shall include a client description, the referral source, presenting and underlying problems, treatment issues, client coping mechanisms, factors contributing to addiction, client strengths and weaknesses, client motivation, support system, client response during the intake, receptivity to treatment and client attitude, ability to participate in treatment, client motivation, support systems, treatment recommendations, diagnosis and prognosis. Emphasis is placed on the documentation of the client ' s strengths, abilities and preferences (SNAP). The assessment shall be submitted promptly (not to exceed 3-5 treatment days after the client's admission to the program) to the Clinical Supervisor for review and signature for residential and within 3 individual sessions for outpatient."
On May 22, 2012 through May 23, 2012, seven client records requiring documentation of a psychosocial evaluation were reviewed. The facility did not document a psychosocial evaluation according to their policy and procedures in three of seven records reviewed, specifically, client records # 5, 6, and 7.
Client # 5 was admitted January 12, 2012 and the psychosocial evaluation was completed on January 24, 2012. However, the psychosocial evaluation did not include an evaluation of the client ' s composite picture, problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, attitude toward treatment, and counselor's conclusion/impressions .
Client # 6 was admitted January 30, 2012 and the psychosocial evaluation was completed on January 3, 2012. However, the psychosocial evaluation did not include an evaluation of the client's assets/strengths, support systems, and coping mechanisms.
Client # 7 was admitted December 23, 2011 and the psychosocial evaluation was completed on January 27, 2012. However, the psychosocial evaluation did not include an evaluation of the client's assets/strengths, support systems, coping mechanisms, attitude toward treatment, and/or counselor's conclusion/impressions.
The findings were confirmed during an interview with the facility director on May 23, 2012 at approximately 3:00 P.M.
This is a repeat citation. The facility was cited on November 21, 2011 and June 2, 2011
for noncompliance with this standard.
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Plan of Correction
In-services will be conducted from June 28, 2012 through July 31, 2012 to review the policy & procedures of Ambulatory Division title "Intake Process/Paperwork," of how to conduct an intake and what documentation is needed for clincial charts. Program and Clinical Supervisor(s) will monitor all clinical charts to ensure that after the completion of the intake, gathering of data for bio-pyschosocial and the written narrative is completed presenting all information. Program Director and Supervisors will be held responsible to ensure that the psychosocial evaluations in the clients records are documented in accordance with the facility policy & procedures. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document a case consultation and/or document a subsequent case consultation in accordance with their policy and procedures.
The findings include:
The facility's policy titled: "Intake Process/Paperwork," states:
"Case Consults are performed every 60 days on all active residential cases (90 days for outpatient) (14 days for short-term). Case Consults are performed more frequently whenever a client has a special problem (s). The Counselor shall meet with the Clinical Supervisor on a regular scheduled basis, i.e., weekly or bi-weekly, to discuss the overall progress or problems of each client. Other counseling staff, nursing personnel, the Medical Director and other relevant staff may also be involved when available. A proposed course of action will be developed for each issue presented. Documentation of the case consults shall be completed by the primary Counselor."
On May 22, 2012 through May 23, 2012, seven client records requiring documentation of a case consultation were reviewed. The facility did not document a case consultation in one of seven records reviewed, specifically, client record # 2. The facility also did not document a subsequent case consultation according to their policy and procedures in one of one record reviewed, specifically, client record # 5.
Client # 2 was admitted January 20, 2012. The case consultation was due no later than April 19, 2012. However, client record # 2 did not include documentation of a case consultation as of May 23, 2012.
Client # 5 was admitted January 12, 2012. The case consultation was due no later than April 11, 2012 and a subsequent case consultation was due no later than May 7, 2012. The case consultation was completed on February 7, 2012. However, the subsequent case consultation was not completed until May 22, 2012.
The findings were confirmed during an interview with the facility director on May 23, 2012 at approximately 3:00 P.M.
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Plan of Correction
Going forward, the supervisor(s) will review the policy & procedures of the time frame case consultations are required in the individuals charts during their weekly staff meeting. Supervisor(s) will ensure that case consultations are conducted with counselors during weekly team meetings & that the primary counselor making written documentation of the case consult(s). The Supervisor(s)will ensure that they are completed every 90 days from time of admission & thereafter. Program and Clinical Supervisor(s) audit client record #2 to ensure the completion of this specific case consultation. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow-up information.
The findings include:
The facility's policy titled: "Follow Up," states:
"All Gaudenzia programs will make reasonable follow up attempts regarding all clients after discharge from any Gaudenzia program (unless the client has made a specific request to not receive a follow up). This is done to ensure that a client who has been referred to another program or service is successfully connected with that program or service. It is also done in order to document the discharged client ' s progress and well being, and if necessary and appropriate, provide an opportunity for re-admission to the program or referral to another appropriate service. Only after such an attempt has been made and documented as described below will Gaudenzia consider its obligation to the individual fulfilled.
If the client is referred to another program or service, Gaudenzia will, having obtained the written consent of the client, attempt via telephone to contact the program to which the client was referred in order to determine the disposition of the referral. This will be completed no later than 7 days after the date of the client's referral appointment.
In instances when the client either refuses a referral to another program or service, or circumstances otherwise prevent such a referral (i.e.: the client leaves against staff advice, declines referral to services after discharge, etc) an attempt will still be made to follow up with the client within 30 days after the date of discharge."
On May 23, 2012, five client records requiring documentation of follow-up information were reviewed. The facility did not document follow-up information in two of five records reviewed, specifically, client records # 8 and 9.
Client # 8 was admitted August 8, 2011 and was discharged December 29, 2011. The follow-up information was due January 28, 2012. However, client record # 8 did not include documentation of follow-up information as of May 23, 2012.
Client # 9 was admitted September 2, 2010 and was discharged January 6, 2012. The follow-up information was due February 5, 2012. However, client record # 9 did not include documentation of follow-up information as of May 23, 2012.
The findings were confirmed during an interview with the facility director on May 23, 2012 at approximately 3:00 P.M.
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Plan of Correction
The Program Director and supervisor(s) will ensure that all individuals (clients) discharges for any reason indiciated that a follow-up is completed. The follow information for client records #8 and 9 have been completed with the follow up documentation. Moving forward all discharge charts will be audit by the Program Director and/or Supervisors weekly after the submission of the charts for final discharge to assure that all individuals that has been discharge was notified according to the folow-up policy & procedure mannual. The charts will be monitor to assure that the proper documentation has been completed and attach to the charts as required. |
709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
Based on a review of client records, the facility failed to comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
The findings include:
The regulation at 55 Pa. Code Part III chapter 1223.52 section (a) subsection 6 (i) - (ii) specifies that "within 15 days following intake, the clinic's supervisory physician shall review and verify each patient's level of care assessment, psychosocial evaluation and initial treatment plan prior to the provision of any treatment beyond the 15th day following intake. The clinic's supervisory physician shall verify the patient's diagnosis. The clinic's supervisory physician shall sign and date the patient's level of care assessment, psychosocial evaluation, treatment plan and diagnosis in the patient's record. Payment will not be made for services provided within or beyond the 15th day following intake, without the clinic's supervisory physician's review and approval of the level of care assessment, psychosocial evaluation, treatment plan and determination of the patient's diagnosis. Sixty days following the date of the initial treatment plan and at the end of every 60-day period during the duration of treatment, the clinic's supervisory physician shall review and update each patient's treatment plan. Each review and update shall be dated, documented and signed in the patient's record by the clinic's supervisory physician."
On May 22, 2012 through May 23, 2012, five client records requiring documentation of a physician's signature on client treatment plans were reviewed. A physician did not sign the individual treatment and rehabilitation plan in four of five records reviewed, specifically, client records # 1, 2, 3, and 4. Also, a physician did not sign the individual treatment and rehabilitation plan in accordance with 55 Pa. Code Part III chapter 1223.52 in one of five records reviewed, specifically, client record # 6. In addition, a physician did not sign an individual treatment and rehabilitation plan update in four of five records reviewed, specifically, client records # 1, 2, 3 and 4. Furthermore, a physician did not sign a subsequent individual treatment and rehabilitation plan update and/or sign a subsequent individual treatment and rehabilitation plan update in five of five records reviewed, specifically, client records # 1, 2, 3, 4, and 6. Moreover, a physician did not sign an individual treatment and rehabilitation plan update and/or subsequent individual treatment and rehabilitation plan update in accordance with 55 Pa. Code Part III chapter 1223.52 in one of five records reviewed, specifically, client record # 6.
Client # 1 was admitted January 19, 2012. A physician was required to sign the individual treatment and rehabilitation plan, the treatment plan update, and subsequent treatment plan updates. The individual treatment and rehabilitation plan was completed March 14, 2012, the treatment plan update was completed March 21, 2012, and subsequent treatment plan updates were completed April 25, 2012 and May 16, 2012. However, the individual treatment and rehabilitation plan, the treatment plan update, and subsequent treatment plan updates did not include documentation of a physician's signature as of May 23, 2012.
Client # 2 was admitted January 20, 2012. A physician was required to sign the individual treatment and rehabilitation plan, the treatment plan update, and the subsequent treatment plan update. The individual treatment and rehabilitation plan was completed February 15, 2012, the treatment plan update was completed March 2, 2012, and the subsequent treatment plan update was completed April 2, 2012. However, the individual treatment and rehabilitation plan, the treatment plan update, and the subsequent treatment plan update did not include documentation of a physician's signature as of May 23, 2012.
Client # 3 was admitted January 5, 2012. A physician was required to sign the individual treatment and rehabilitation plan and the treatment plan update. The individual treatment and rehabilitation plan was completed February 21, 2012 and the treatment plan update was completed March 21, 2012. However, the individual treatment and rehabilitation plan and the treatment plan update did not include documentation of a physician's signature as of May 23, 2012.
Client # 4 was admitted January 26, 2012. A physician was required to sign the individual treatment and rehabilitation plan and the treatment plan update. The individual treatment and rehabilitation plan was completed March 13, 2012 and the treatment plan update was completed April 13, 2012. However, the individual treatment and rehabilitation plan and the treatment plan update did not include documentation of a physician's signature as of May 23, 2012.
Client # 6 was admitted January 30, 2012. A physician was required to sign the individual treatment and rehabilitation plan within 15 days of the date of completion of the individual treatment and rehabilitation plan. In addition, sixty days following the date of the individual treatment and rehabilitation plan and at the end of every 60-day period during the duration of treatment, the clinic's supervisory physician a physician was required to sign the treatment plan update and subsequent treatment plan updates. The individual treatment and rehabilitation plan was completed January 30, 2012, the treatment plan update was completed February 24, 2012, and the subsequent treatment plan updates were completed April 24, 2012 and May 22, 2012. However, the individual treatment and rehabilitation plan was not signed by a physician until May 8, 2012, the treatment plan update was not signed by a physician until May 8, 2012, the first subsequent treatment plan update was not signed by a physician until May 8, 2012, and the second subsequent treatment plan update did not include documentation of a physician ' s signature as of May 23, 2012.
The findings were confirmed during an interview with the facility director on May 23, 2012 at approximately 3:00 P.M.
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Plan of Correction
According to regulations at 55 Pa. Code Part III (relating to Medical Assistance Manual) the agency will ensure that the facility stay in compliance with the state regulations and have the supervisory physician review all clinical charts and apply his/her signature as required within the timeframe following the intake procedure. The Program Director will ensure that the supervisory physician apply his/her signature to treatment plans as required by 55 Pa. Code Part III.
The supervisory physician is schedule to sign all clinical charts on a bi-weekly basis. Charts has been reviewed by Program Director/Supervisors to assure that signatures has been applied in the clincal charts as required by 55 Pa. Code Part III. Charts # 1, 2, 3 & 4 has been reviewed and the supervisory physican has signed charts as required. |