INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and buprenorphine monitoring inspection conducted on October 7 - 9, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Erie Inc. Crossroads 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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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on a review of personnel records and discussions with the project director, the facility failed to appoint a facility director who met the appropriate qualifications. Qualifications for project/facility director include educational requirements, and experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
The findings include:
Employee #1 was promoted to facility director on September 13, 2013, but does not meet the experiential qualifications for the position. Employee #1 does not have program planning experience.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director attended Program Management Training on October 13th, 2014 and October 14th, 2014 which included Program Planning. this training was conducted by the Gaudenzia Training Institute.
Program Director will also be attending the DDAP Clinical Supervisory Training scheduled for December 2014. |
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 one of one client records.
The findings include:
Nine client records were reviewed on October 7-8, 2014. Seven of the client records reviewed were discharged clients. One of the discharged clients was involuntarily terminated from treatment at the project. The facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, in client record # 7.
Client # 7 was admitted into treatment on September 18, 2014 and was involuntarily terminated from the project on September 26, 2014. There was no documentation of written notification provided to the client as of the on-site inspection which was conducted October 7-9, 2014.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Supervisor will review the requirement of having notification of involuntarily discharging a client placed in the client record with all clinical staff by November 30th, 2014.
Clinical Supervisor will complete monthly chart audits of client records and will report any issues with lack of documentation showing that a client was informed of involuntary discharge to the Program Supervisor. these monthly chart audits will begin December 2014. |
709.62(c)(1) LICENSURE Disclosure documentation
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on a review of client records, the facility failed to provide documentation of the disclosure to the client of criteria for admission, treatment, completion and discharge.
The findings include:
Nine client records were reviewed on October 7 - 8, 2014. Four of the client records were for the detoxification activity. Two client records, # 1 & #2, failed to include documentation of the disclosure to the client of criteria for admission, treatment, completion and discharge.
Client #1 was admitted to treatment on September 8, 2014 and was discharged on September 12, 2014. As of the date of the licensing inspection, the disclosure of criteria for admission, treatment, completion and discharge was not documented.
Client #2 was admitted to treatment on August 6, 2014 and was discharged on August 11, 2014. As of the date of the licensing inspection, the disclosure of criteria for admission, treatment, completion and discharge was not documented.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Nurse Manager will review, with all nurses and house managers, the requirement of making sure that all clients entering detox must be made aware of admission, treatment, completion and discharge criteria and that this must be documented in the client record. Nurse manager will have this meeting with staff by December 1st, 2014.
Nurse Manager will complete monthly chart audits to assure client criteria for admission, treatment, discharge and completion has been reviewed with clients and documentation has been placed in client record starting in December 2014. |
709.62(c)(2)(i) LICENSURE Orientation Proj policies
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(2) Client orientation to the project which includes, but is not limited to a familiarization with:
(i) Project policies, which include the following:
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Observations
Based on a review of client records, the facility failed to provide documentation of the client orientation to the project which includes the following: project policies, hours of operation, fee schedule, and services provided.
The findings include:
Nine client records were reviewed on October 7 - 8, 2014. Four of the client records were for the detoxification activity. Two client records, # 1 & #2, failed to include documentation of the client orientation to the project which includes the following: project policies, hours of operation, fee schedule, and services provided.
Client #1 was admitted to treatment on September 8, 2014 and was discharged on September 12, 2014. As of the date of the licensing inspection, the disclosure of client orientation was not documented.
Client #2 was admitted to treatment on August 6, 2014 and was discharged on August 11, 2014. As of the date of the licensing inspection, the disclosure of client orientation was not documented.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Program Supervisor will review with all staff the requirement that all clients being admitted into the program need to have documentation that they were oriented into the program and he will review this with staff by December 1st, 2014.
Clinical Supervisor will complete chart audits monthly to assure client orientation has been documented and the clinical supervisor will share these results in the monthly QI/UR meeting starting in December 2014. |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Based on a review of patient records, the facility failed to obtain an informed, voluntary, written consent prior to the administration of a narcotic agent for detoxification treatment.
The findings include:
Four patient records were reviewed for buprenorphine detoxification on October 7 - 8, 2014. Four patient records were reviewed for the completion of an informed, voluntary written consent prior to the administration of a narcotic agent. The facility failed to document the completion of an informed, voluntary, written consent prior to the administration of a narcotic agent in patient record # 2.
Patient # 2 was admitted into treatment on August 6, 2014 and was discharged on August 11, 2014. The patient received their initial dose of buprenorphine on August 7, 2014. There was no documentation of an informed, voluntary written consent prior to the administration of a narcotic agent in patient record # 2.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Nurse Manager will meet with all the nurses and educate them about the requirement and necessity to have the informed consent signed by clients for all individuals receiving buprenorphine. Nurse manager will educate them by December 1st, 2014.
Nurse manager will audit all files of individuals receiving buprenorphine and review for the informed consent. Nurse manager will report her findings in the monthly QI/UR meeting starting in December 2014. |
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 provide a complete client record on each individual in four of six client records.
The findings include:
Nine client records were reviewed on October 7-8, 2014. Six client records were reviewed for the inpatient non-hospital - residential treatment activity, and complete client records were required. The facility did not provide a complete client record for records #4, 5, 6 and 7.
Client #4 was admitted to treatment on March 10, 2014 and was discharged on June 2, 2014. Record #4 did not have documentation of the record of services for the months of April 2014 and June 2014. In addition, the individual sessions and the group sessions were not included on the record of service for March 2014 and May 2014.
Client #5 was admitted to treatment on July 31, 2014 and was discharged on September 5, 2014. Record #5 did not have documentation of a case consultation, discharge summary and record of service. Record of service was missing for the month of September 2014. In addition, the individual sessions and the group sessions were not included on the record of service for August 2014.
Client #6 was admitted to treatment on August 8, 2014 and was discharged on September 20, 2014. Record #6 did not have documentation of the record of service or progress note for a family session. Record of service for the month of August 2014 only includes one family session on August 15, 2014, but the documentation of the progress note was missing. The group sessions were not included on the record of service for August 2014 and September 2014.
Client #7 was admitted to treatment on September 18, 2014, and was discharged on September 26, 2014. Record #7 did not have documentation of a case consultation, discharge summary, progress notes and record of service. Record of service was missing for the month of September 2014. In addition, there are only two progress notes documented for this treatment experience; one individual session and one group session.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Program Supervisor will meet with all clinical staff and review documentation requirements and time frames. program Supervisor will have this meeting by December 1st, 2014.
Division Director will schedule a clinical record keeping training for clinical staff to be held prior to January 1st, 2015. All clinical staff that have not had this training will be required to attend.
Clinical Supervisor will complete monthly chart audits and report findings as they relate to the complete clinical documentation/record in the monthly QI/UR meeting. |