INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 17, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Outpatient was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the fire drill record log and an interview with the clinical supervisor, the facility failed to document two monthly fire drills in the last year.
The findings include:
The fire drill record log was reviewed on May 17, 2011. The log was reviewed from the time period covering May 2010 to April 2011. There was no documentation that a fire drill had been conducted for two of those months reviewed. Drills had not been conducted for May 2010 and September 2010.
The missing fire drills entries were confirmed with an interview with the clinical supervisor during an interview on May 17, 2011.
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Plan of Correction
As of October 2010 a new Administrative Coordinator was hired. It is her responsibility to ensure that the required amount of fire drills are completed and documented monthly per standards. The Administrative Coordinator will schedule and conduct the drills. If she is not in the building, she will call in to her administrative staff on duty to conduct and document the drill in the fire drill log. The new A.C. was trained by 10/31/10 on this procedure by an experienced A.C.
Fire drill compliancy will be monitored monthly by the Safety Committee, the CQI Director and in weekly administrative meetings with the Program Supervisor, the Division Director and the Administrative Coordinator.
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709.92(a) LICENSURE Treatment and rehabilitation services
709.92. 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 the review of client records, the facility's policy and procedures manual, and an interview with the clinical supervisor, the facility failed to document an individual treatment and rehabilitation plan in accordance with the facility's policy and procedures in four of twelve client records.
The findings include:
On May 17, 2011, twelve client records requiring treatment and rehabilitation plans were reviewed. The facility did not document an individual treatment and rehabilitation plan based on information collected in client histories within the first three sessions of the client's admission, as per facility policy, in client records # 1 and 11.
The facility's policy titled "PROCEDURE FOR INDIVIDUAL TREATMENT & REHABILITATION PLAN" States:
"An individualized treatment and rehabilitation plan will be developed with each client after the completion of the client's psycho-social evaluation. The counselor will create, with the client, a proposed treatment plan, based on information collected in patient histories, the bio-psycho-social and assessment and the clients [sic] problem list. The plan will be discussed with the client and changes made upon client request as appropriate."
"The treatment plan will be signed by the Client, the Primary Counselor, the Clinical Supervisor, physician (when applicable) and placed in the client record. 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) or by the third session (outpatient).Chesapeake region requires an initial TP within 24 hours)."
In client record #1, was admitted on March 8, 2011. The treatment and rehabilitation plan was completed prior to the completion of the biopsychosocial assessment. There was no psychosocial assessment completed for client #1; but the treatment plan was dated 3/30/11.
In client record #11, was admitted on January 31, 2011. The treatment and rehabilitation plan was completed prior to the completion of the biopsychosocial assessment. There was no psychosocial assessment completed for client #11; but the treatment plan was dated 1/31/11.
In client record #12, the record of services stated individual counseling sessions occurred on 1/27/11, 2/24/11, 3/9/11, 3/31/11, 4/14/11, but the record did not contain an individual treatment and rehabilitation plan.
In client record #6, the record of services stated individual counseling sessions occurred on 12/24/10, 12/28/10, and 1/11/11, but the individual treatment and rehabilitation plan was not documented until 1/25/11.
This was confirmed with the clinical supervisor on May 17, 2011.
This is a repeat citation.
The facility was previously cited for noncompliance with this standard during the licensing inspection conducted on April 21, 2011.
In response to the citation issued on April 21, 2011, the facility's plan of correction submitted on 5/24/2011 and approved on 5/24/2011 stated the following:.
"An in-service will be held by the Program Supervisor on June 10, 2011 to address timelines and steps required to complete the initial treatment plan. All clinicians will be directed to complete the bio-psychosocial assessment within the first three sessions. A client driven treatment plan will be completed at the end of the third session. The evaluation and admission appointment have been extended to 1 1/2 hours each to allow for completion of the bio-psychosocial and assessment. All staff will be directed that no treatment plans will be developed without referring to a completed client assessment.
Clinical staff will be monitored in regular supervisory sessions to include corrective action for failure to comply. Compliancy will be discussed in a weekly administrative meeting.
Program Supervisor and Program Director will monitor compliance utilizing the monthly CQI process"
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Plan of Correction
An in-service will be held by the Program Supervisor on June 17, 2011 to address timelines and steps required to complete the initial treatment plan. All clinicians will be directed to complete the bio-psychosocial assessment within the first three sessions. A client driven treatment plan will be completed at the end of the third session. The evaluation and admission appointment have been extended to 1 1/2 hours each to allow for completion of the bio-psychosocial and assessment. All staff will be directed that no treatment plans will be developed without referring to a completed client assessment.
Clinical staff will be monitored in regular supervisory sessions to include corrective action for failure to comply. Compliancy will be discussed in a weekly administrative meeting.
Program Supervisor and Program Director will monitor compliance utilizing the monthly CQI process.
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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 the review of client records, the facility's policy and procedure manual, and a conversation with the clinical director, the facility failed to document follow-ups in accordance with the facility's policies and procedures in four of five client records.
The findings include:
Fourteen client records were reviewed on May 17, 2011. Documentation of a follow-up was required in five of those records. The facility failed to document follow-up information in accordance with the facility's policies and procedures in client records # 8, 11, 13, and 14.
The facility's policy titled, FOLLOW UP INFORMATION states:
In the case where a client has been referred to a specific outside resource for continued care post discharge from the project, follow up should be completed via a telephone call with the resource within one week of the client's initial referral appointment to the resource. Once the attempt has been made and documented in the follow up log binder, a program may consider its obligation to the individual fulfilled. This procedure will follow for client ' s who are not referred after discharge. The worker will attempt to contact the client directly via telephone and document the findings in the log binder.
Where clients are not referred after discharge, the clinical supervisor or their designee will call the client in 30 days. Contact will be logged in the Follow Up Log binder.
Client # 8 was admitted on October 12, 2010 and discharged on April 12, 2011. The client was not referred to an outside source. A follow up attempt should have been made to the client by May 12, 2011, there was no documentation of a follow-up during the time of inspection.
Client # 11 was admitted on January 31, 2011 and discharged on March 23, 2011. The client was not referred to an outside source. A follow up attempt should have been made to the client by April 23, 2011, there was no documentation of a follow-up during the time of inspection.
Client # 14 was admitted on December 7, 2010 and discharged on February 17, 2011. The client was not referred to an outside source. A follow up attempt should have been made to the client by March 17, 2011, there was no documentation of a follow-up during the time of inspection.
Client # 13 was admitted on November 9, 2010 and discharged on April 1, 2011. The client was not referred to an outside source. A follow up attempt should have been made to the client by May 1, 2011, However the follow up had not been documented until May 13, 2011.
The lack of follow-up documentation had been confirmed with the facility director, during a conversation on May 17, 2011.
This is a repeat citation.
The facility was previously cited for noncompliance with this standard during the licensing inspection conducted on May, 14, 2009.
In response to the citation issued on May 14, 2009, the facility's plan of correction submitted on 6/9/2009 and approved on 7/9/2009 stated the following:
"Follow up per policy and procedure will be fully implemented by the Program Supervisor and the Administrative Coordintor [sic]. Completion of follow up will be monitored monthly in the Administrative meeting for policy compliance and documented in the minutes. Monitoring of this compliance will be completed by the Division Director."
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Plan of Correction
On May 24, 2011 a meeting was held with the Divison Director, Program Supervisor, Clinical Supervisor and Administrative Coordinator to review the policy on follow up procedures. At that time the direction was given that Clinical Staff would be responsible for completion of all follow ups.
On May 27, 2011 Clincial Staff were informed of their new reponsibilites regarding follow up procedures.
The first follow up will be completed within 7 days of discharge. The second follow up will be completed within 30 days of discharge regardless of discharge or referral status.
Both follow ups will be documented on the same form.
Forms will be forwarded monthly to administrative staff to be filed in a central follow up binder. All completed forms will be reviewed monthly during an administrative meeting.
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709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of areas of noncompliance identified during this licensing inspection that had previously been cited, the facility failed to comply with prior plans of correction approved by the Department.
The findings include:
On May 17, 2011 the facility was again found to be out of compliance with the following standards:
709.92(a). Treatment and rehabilitation services. An individual treatment and rehabilitation plan shall be developed with a client.
The facility was previously cited for noncompliance with this standard during the licensing inspection conducted on April 21, 2011 (plan of correction submitted on 5/24/2011 and approved on 5/24/2011).
709.93(11) Client records. Follow-up information.
The facility was previously cited for noncompliance with this standard during the licensing inspection conducted on May, 14, 2009 (plan of correction submitted on 6/9/2009 and approved on 7/9/2009).
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Plan of Correction
In reference to cite 709.92 issued on April 21, 2011 and on May 17, 2011, a plan of correction was submitted and approved by Licensing on May 24, 2011. The completion date for the corrections was June 3, 2011. All plan of correction action steps have been implemented.
To ensure compliancy, the Division Director will meet with the Program and Clinical Supervisors respectively to review the approved POC. Each supervisor will then meet with their staff to review the POC. The Division Director shall be present for this meeting.
The Division Director will meet with the Program Supervisors monthly to review progress in the cited deficiency areas. This will be documented in Administrative Meeting minutes and /or supervisory notes.
Should the Division Director observe deviation from an approved POC, the Director will develop and implement an action plan for the Program Supervisors. In the future, should the Division Director experience difficulty with the POC compliance, the Division Director will immediately submit to the Department a request for extension or modification to the approved POC.
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