INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted from August 13, 2014 to August 14, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia, Inc. Broad Street 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 of counselor in one of two personnel records reviewed.
The findings include:
Two personnel records were reviewed for documentation of the qualifications for the position of counselor. The facility failed to ensure that employee # 4 met the qualifications for the position of counselor.
Employee # 4 was hired as an Associate's level counselor on March 24, 2014. The facility failed to verify that employee # 4 met the educational qualifications for the position of counselor. Employee # 4 has an Associate's degree. However, a review of the college transcript and personnel record for employee # 4 indicated that the Associate's degree was in Liberal Arts, a non-qualifying major.
The findings were presented to the clinical supervisor, facility director, and division director on August 14, 2014.
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Plan of Correction
704.7(b)Counselor Qualifications
Plan of Correction
Gaudenzia Broad Street will hire only clinical staff who meet the educational and experiential qualifications as required by the Division of Drug and Alcohol Licensure per DOH Policy 704.7(b)Counselor Qualifications.
The facility will attempt to obtain a letter from the university to qualify Employee #4 and their degree for the position of counselor. If we are unable to secure the letter we will place Employee #4 in a Counselor Assistant Position.
The Director of Human Resources and Compliance Officer will review each new counselor hire package to ensure that the clinical staff meets the educational and experiential qualifications per DOH Policy 704.7(b)Counselor Qualifications.
Persons Responsible: Human Resources Director, Compliance Officer, Program Director, Program Supervisor.
Timeframe for Completion: September 15,2014 |
709.51(b)(2)(i) LICENSURE Client Orientation to Project
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(i) Project policies.
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Observations
Based on a review of client records, the facility failed to document client orientation to the project that included hours of operation and a fee schedule in ten of ten client records reviewed.
The findings include:
Ten client records requiring documentation of client orientation to the project were reviewed from August 13, 2014 to August 14, 2014. The facility failed to document client orientation to the project that included hours of operation and a fee schedule in client records # 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10.
The findings were confirmed with the clinical supervisor, facility director, and division director on August 14, 2014.
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Plan of Correction
709.51(b)(2)(i) Client Orientation
Plan of Correction
The Gaudenzia Broad Street Orientation Handbook was updated to include the primary hours of operation 9:00am-5:00pm and to notify the residents where the fee schedule is in the waiting area. There will an Acknowledgement Form that is signed by the residents and put into their chart acknowledging that they have received the handbook. The program supervisor will ensure that residents #1, #2,#3, and #4 have reviewed the resident handbook,are aware of the hours of operation and fee schedule and have a signed acknowledgement form in their chart. Residents #5, #6, #7, #8, #9 and #10 have been discharged.
A record-keeping training with staff will be facilitated on September 22, 2014 to review the updated Gaudenzia Broad Street Orientation Handbook. The training will ensure that all staff are trained to familiarize the residents with project policies as required by the Division of Drug and Alcohol Licensure per DOH Policy 709.51(b)(2)(i).
Monthly Continuous Quality Improvement (CQI) meetings will ensure compliance, completion, and timelines by the Program Director.
Persons Responsible:
Program Director, Program Supervisor.
Timeframe for Completion: September 22, 2014
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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 a review of client records, the facility failed to document a drug or alcohol history and a personal history of the client in three of ten client records reviewed.
The findings include:
Ten client records requiring documentation of a drug or alcohol history and a personal history were reviewed from August 13, 2014 to August 14, 2014. The facility failed to document a drug or alcohol history and personal history in client records # 2, 4, and 6.
Client # 2 was admitted February 24, 2014 and was still an active client as of 8/14/14. The drug or alcohol history and personal history was due March 1, 2014. However, client record # 2 did not include documentation of a drug or alcohol history and personal history as of August 14, 2014.
Client # 4 was admitted February 18, 2014 and was still an active client as of 8/14/14. The drug or alcohol history and personal history was due February 23, 2014. However, client record # 4 did not include documentation of a drug or alcohol history and personal history as of August 14, 2014.
Client # 6 was admitted February 20, 2014 and was discharged April 6, 2014. The drug or alcohol history and personal history was due February 25, 2014. However, client record # 6 did not include documentation of a drug or alcohol history and personal history as of August 14, 2014.
The findings were confirmed with the clinical supervisor, facility director, and division director on August 14, 2014.
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Plan of Correction
709.51(b)(3)(ii) Drug and Alcohol History
Plan of Correction
A record-keeping training with staff will be facilitated on September 22, 2014 to review 709.51(b)(3)(ii) Drug and Alcohol History
The training will ensure that all staff are trained to document a drug and alcohol history and a personal history as required by the Division of Drug and Alcohol Licensure per DOH Policy 709.51(b)(3)(ii) Drug and Alcohol History.
The program supervisor will ensure that the drug and alcohol history along with the personal history will be documented in resident charts #2 and #4. Resident #6 has been discharged.
Monthly Continuous Quality Improvement (CQI) meetings will ensure compliance, completion, and timelines by the Program Director.
Persons Responsible:
Program Director, Program Supervisor.
Timeframe for Completion: September 22, 2014
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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 a review of client records, the facility failed to document a psychosocial evaluation of the client in three of ten records reviewed.
The findings include:
Ten client records requiring documentation of a psychosocial evaluation were reviewed from August 13, 2014 to August 14, 2014. The facility failed to document a psychosocial evaluation in client records # 2, 4, and 6.
Client # 2 was admitted February 24, 2014 and was still an active client as of 8/14/14. The psychosocial evaluation was due March 1, 2014. However, client record # 2 did not include documentation of a psychosocial evaluation as of August 14, 2014.
Client # 4 was admitted February 18, 2014 and was still an active client as of 8/14/14. The psychosocial evaluation was due February 23, 2014. However, client record # 4 did not include documentation of a psychosocial evaluation as of August 14, 2014.
Client # 6 was admitted February 20, 2014 and was discharged April 6, 2014. The psychosocial evaluation was due February 25, 2014. However, client record # 6 did not include documentation of a psychosocial evaluation as of August 14, 2014.
The findings were confirmed with the clinical supervisor, facility director, and division director on August 14, 2014.
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Plan of Correction
709.51(b)(6)Psychosocial Evaluation
Plan of Correction
A record-keeping training with staff will be facilitated on September 22, 2014 to review 709.51(b)(6)Psychosocial Evaluation.
The training will ensure that all staff are trained to document a psychosocial evaluation of the resident as required by the Division of Drug and Alcohol Licensure per DOH Policy 709.51(b)(6)Psychosocial Evaluation.
The program supervisor will ensure that the psychosocial evaluations will be documented in resident charts #1, #2 and #4. Residents #5 and #7 have been discharged.
Monthly Continuous Quality Improvement (CQI) meetings will ensure compliance, completion, and timelines by the Program Director.
Persons Responsible:
Program Director, Program Supervisor.
Timeframe for Completion: September 22, 2014
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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, the facility failed to document treatment and rehabilitation plan updates at least every 60 days in six of six client records reviewed.
The findings include:
Six client records requiring documentation of treatment and rehabilitation plan updates were reviewed from August 13, 2014 to August 14, 2014. The facility failed to document a treatment and rehabilitation update at least every 60 days in client records # 1, 2, 4, 5, 7, and 10.
Client # 1 was admitted February 18, 2014 and was still an active client as of 8/14/14. The individual treatment plan was completed March 13, 2014 and the treatment plan update was due April 14, 2014. However, client record # 1 did not include documentation of a treatment plan update as of August 14, 2014.
Client # 2 was admitted February 24, 2014 and was still an active client as of 8/14/14. A treatment plan update was completed June 28, 2014 and another treatment plan update was due July 28, 2014. However, client record # 2 did not include documentation of an additional treatment plan update as of August 14, 2014.
Client # 4 was admitted February 18, 2014 and was still an active client as of 8/14/14. A treatment plan update was completed April 24, 2014 and another treatment plan update was due May 24, 2014. However, client record # 4 did not include documentation of an additional treatment plan update as of August 14, 2014.
Client # 5 was admitted March 10, 2014 and was still an active client as of 8/14/14. The individual treatment plan was completed April 8, 2014 and the treatment plan update was due May 8, 2014. However, client record # 5 did not include documentation of a treatment plan update as of August 14, 2014.
Client # 7 was admitted February 12, 2014 and discharged May 3, 2014. The individual treatment plan was complete February 18, 2014 and the treatment plan update was due March 20, 2014. However, client record # 7 did not include documentation of a treatment plan update as of August 14, 2014.
Client # 10 was admitted March 19, 2014 and discharged June 4, 2014. A treatment plan update was completed May 1, 2014 and another treatment plan update was due June 2, 2014. However, client record # 10 did not include documentation of an additional treatment plan update as of August 14, 2014.
The findings were confirmed with the clinical supervisor, facility director, and division director on August 14, 2014.
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Plan of Correction
709.52(b)Treatment Plan Update
Plan of Correction
A record-keeping training with staff will be facilitated on September 22, 2014 to review DDAP DOH Policy 709.52(b)Treatment Plan Updates.
The training will ensure that treatment and rehabilitative plans are reviewed and updated at least every 30 days as required by the Division of Drug and Alcohol Licensure per DOH Policy 709.52(b)Treatment and Rehabilitative Services.
The program supervisor will ensure that the treatment plan updates will be documented in resident charts #1, #2 and #4. Residents #5 and #7 have been discharged.
Monthly Continuous Quality Improvement (CQI) meetings will ensure compliance, completion, and timelines by the Program Director.
Persons Responsible:
Program Director, Program Supervisor.
Timeframe for Completion: September 22, 2014
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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 a review of client records, the facility failed to document a complete client record that included a record of services in three of ten client records reviewed and an individual treatment and rehabilitation plan in three of ten client records reviewed. Also, the facility failed to document a complete client record that verified that work done by the client at the project was an integral part of his treatment and rehabilitation plan in one of seven client records reviewed.
The findings include:
Ten client records requiring documentation of a complete client record were reviewed from August 13, 2014 to August 14, 2014. The facility failed to document a record of services in client records # 3, 8, and 9. The facility failed to document an individual treatment and rehabilitation plan in client records # 3, 6, and 8. Also, the facility failed to document verification of work therapy in the comprehensive treatment plan and treatment plan update in client record # 4.
Client # 3 was admitted January 31, 2014 and discharged March 31, 2014. The record of services was missing for group counseling services dated 3/23/14 and 3/30/14. Also, the individual treatment and rehabilitation plan was due March 4, 2014. However, client record # 3 did not include documentation of an individual treatment and rehabilitation plan as of August 14, 2014.
Client # 4 was admitted February 18, 2014 and was still an active client as of 8/14/14. The comprehensive treatment plan was completed March 25, 2014 and the treatment plan update was completed April 24, 2014. The facility was required to document work therapy on the comprehensive treatment plan and treatment plan update. However, client record # 4 did not include documentation of work therapy in the comprehensive treatment plan and treatment plan update as of August 14, 2014.
Client # 6 was admitted February 20, 2014 and discharged April 6, 2014. The individual treatment and rehabilitation plan was due March 22, 2014. However, client record # 6 did not include documentation of an individual treatment and rehabilitation plan as of August 14, 2014.
Client # 8 was admitted January 24, 2014 and discharged April 10, 2014. The individual treatment and rehabilitation plan was due February 23, 2014. However, client record # 8 did not include documentation of an individual treatment and rehabilitation plan as of August 14, 2014. Also, the record of services was missing for group counseling services dated 4/2/14, 4/4/14, 4/5/14, and 4/6/14.
Client # 9 was admitted April 15, 2014 and discharged June 3, 2014. The record of services was missing from April 2014 to June 2014.
The findings were confirmed with the clinical supervisor, facility director, and division director on August 14, 2014.
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Plan of Correction
Plan of Correction
709.53(a)Complete Client Record
A record-keeping training will be facilitated on September 22, 2014 to review including the Record of Service and any work done by the client to be documented as an integral part of the treatment and rehabilitation plan as required by the Division of Drug and Alcohol Licensure per DOH Policy 709.53(a)Complete Client Record.
The program supervisor will ensure that work therapy is documented in the treatment plan update of resident #4's chart.
All treatment planning documentation will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings by the Program Director and Program Supervisor.
Persons Responsible:
Program Director
Program Supervisor
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