INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 13-15, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Gaudenzia DRC Inc. 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
During a licensing inspection conducted on January 13-15, 2020, the facility failed to provide documentation of a qualifying degree for employee # 6.
Employee # 6 was hired as a counselor on September 4, 2019 and was still in this position at the time of the inspection. After review of the employee personnel record, it was determined the employee had a bachelor ' s degree in communications, which is a non-qualifying degree for a counselor position.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Counselor #6 had the counseling experience but a non-qualifying degree. Counselor #6 employment was terminated effective 1/24/20. The Outpatient Director/Clinical Supervisor will review the degree and transcripts of the applicant to determine if the qualifications for the counsel position are met. The Human Resources Department will confirm the qualifications are met before offering a position of employment as a counselor. The Outpatient Director, Clinical Supervisor and Human Resources Director will meet to review the DDAP qualifications and screening process for Alcohol and Other Drug counselors applicants. |
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
During a licensing inspection conducted on January 13-15, 2020, the facility failed to provide comprehensive treatment plans according to the facilities policy and procedure manual. The facility's policy and procedure indicated a comprehensive treatment plan be developed with the client within seven days of admission or the clients third or fourth session.
Client # 1 was admitted on August 28, 2019 and was still active at the time of the inspection. A preliminary treatment plan was developed on August 28, 2019. The comprehensive treatment plan was not developed until January 13, 2020.
Client # 2 was admitted on September 25, 2019 and was still active at the time of the inspection. A preliminary treatment plan was developed on August 25, 2019. The comprehensive treatment plan was not developed until November 8, 2019.
Client # 3 was admitted on November 11, 2019 and was still active at the time of the inspection. The comprehensive treatment plan was not developed until December 5, 2019.
Client # 4 was admitted on September 10, 2019 and was still active at the time of the inspection. The comprehensive treatment plan was not developed until October 10, 2019.
Client # 5 was admitted on May 10, 2019 and was discharged on November 15, 2019. The comprehensive treatment plan was not developed until August 6, 2019.
Client # 6 was admitted on May 22, 2019 and was discharged on November 29, 2019. The comprehensive treatment plan was not developed until August 16, 2019.
Client # 7 was admitted on March 26, 2019 and was discharged on June 20, 2019. A preliminary treatment plan was developed on March 26, 2019. The comprehensive treatment plan was not developed until May 20, 2019.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Individualized treatment plans shall be formally updated every 30 days (Intensive Outpatient) or 60 days (Outpatient) utilizing a treatment plan update form.
During clinical staff meeting, the primary counselor shall present a verbal case report for team consultation. Treatment progress shall be documented on the case consultation form.
Depending on participant progress and recommendations of the clinical team, goals may be deleted, added or revised as needed. Documentation shall be made on the original treatment plan or updated treatment plan accordingly. Outpatient Clinical Supervisor/Program Director will review treatment plan due dates during weekly supervision. There will be supervisions had with the respective counselors for Client #1, Client # 2, Client #4, Client #5, Client #6 and Client #7 regarding treatment plans that were not completed within the specified time frame.
Client #3 comprehensive plan was in compliance because it was completed within 30 days of admittance into the Outpatient program.
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709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
During a licensing inspection conducted on January 13-15, 2020, the project failed to provide a complete client rights policy and procedure to include reasons for removing sections shall be documented in the record.
These findings were reviewed with project staff during the licensing inspection.
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Plan of Correction
PLAN OF CORRECTION: Policy 709.30.3 POLICY FOR PARTICIPANT ACCESS TO RECORDS, TEMPORARY REMOVAL OF PORTIONS OF THE RECORD & PARTICIPANT RIGHT TO REBUTTAL. All participants shall have the right to inspect their own records.
PROCEDIRES:
Requests to review records must be made in writing to the Program Director and must bear the participant's original dated signature. An appointment for the participant's record review will be scheduled within two weeks of the request, to allow the Program and Medical Directors and Clinical Supervisor adequate time to preview the record. Participants must view their record in the presence of their Counselor or the Clinical Supervisor.
Portions of the record may be temporarily removed by order of the Medical/Program Director, prior to inspection by the participant, if it is determined that the information may be detrimental if presented to the participant. Upon receipt of a participant's request to view his record, the Program Director will determine any items to be temporarily removed and the Clinical Supervisor shall assure that the removal is completed.
All items temporarily removed from the participant's record and the reason for their removal shall be documented on the "Temporary Record Removal" form by the person removing the items. The form must then be signed by the Clinical Supervisor and the Medical Director. The removed items shall be placed in a manila folder, along with a copy of the "Temporary Record Removal" form, labeled with the participant's name and case number and will be stored in the participant record filing cabinet.
After the participant has completed the record review, the Clinical Supervisor shall assure that those items, which were temporarily removed, are reentered into the participant's record within two working days.
Participants have the right to appeal a decision to limit their access to their records. Participant appeals must be submitted in written format to the Program Director.
Participants have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information from their records. Such requests must be made in writing to the Program Director, who will discuss data corrections with the participant before record alterations are made.
Participants have the right to submit rebuttal data or memoranda to their own records.
The Outpatient policy and procedure manual was reviewed and updated for 2020 by the Outpatient Director. The policy and procedures regarding participant access to records, temporary removal of portions of the record and participant right to rebuttal will be revewed by the Outpatient Director with Outpatient staff during staff meeting on 3/10/20. Staff members will sign attendance sheet for the Policy review. |
709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
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Observations
During a licensing inspection conducted on January 13-15, 2020, 2019, the project ' s policy and procedure manual failed to provide procedures for responding to a physical assault or sexual assault by staff or a client.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
709.30 Policy of Reporting of Unusual Incidents ?POLICY: Gaudenzia DRC Programs and committed to ensuring the safety and dignity of all participants whom we provide services. Gaudenzia DRC does not tolerate any type of physical abuse, sexual abuse or sexual harassment of any individual under our care. Procedures: Upon learning of an allegation that a participant was physically or sexually abused: the first staff member to respond shall call for help/backup (911). Staff member will separate the alleged victim and abuser, if they have not already been separated. Staff member will secure and protect any crime scen until appropriate steps can be taken to collect any evidence. Staff member will complete a Significant Incident Report for the occurrence and give to the Director prior to leaving for the day. Program Director will complete all unusual incidents and submit the document to the appropriate funding sources. The policy and procedure for reporting unusual incidents of physical assault or sexual assault by staff or a client will be reviewed during staff meeting on 3/10/20. Staff members will sign attendance sheet for the Policy review. |
709.34 (a) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(2) Selling or use of illicit drugs on the premises.
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Observations
During a licensing inspection conducted on January 13-15, 2020, 2019, the project ' s policy and procedure manual failed to develop and implement procedures in responding to selling or use of illicit drugs on the premises.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
709.34 (a) (2) Gaudenzia DRC prohibits the use of illicit drugs or the selling of illicit drugs on the premises. The use of illegal drugs or abuse of alcohol by our employees is entirely inconsistent with our mission. Consequently, the following conduct is prohibited and cause for immediate discharge:
1. The use, possession, manufacture, sale, dispensation or distribution of illegal drugs while on duty (including any unpaid breaks) or while on Company premises.
2. The possession of alcohol while on DRC premises, in a DRC vehicle, or while on duty (including any unpaid breaks).
3. Use or consumption of alcohol in the four (³) hour period prior to coming to work, while on DRC premises, in a DRC vehicle, or while on duty (including any unpaid breaks).
4. Being on DRC premises, in a DRC vehicle, or while on duty (including any unpaid breaks) with the odor of alcohol on your breath.
5. Being under the influence of or affected by illegal drugs or alcohol while on DRC premises, in a DRC vehicle, or while on duty (including any unpaid breaks).
6. Use of drugs or abuse of alcohol by any employee under such other circumstances which may be detrimental to the Agency's reputation and/or our clients best interest.
Additionally, if the Director of the facility receives notice from an employee of any criminal drug statute conviction for a violation occurring in the workplace, the Director or designee will notify the Single County Authority within 10 days. ? Procedures for reporting Selling or use of illicit drugs on the premises - Staff member will report to the Program Director or designee anyone who appears to be under the influence of drugs or alcohol. The Director or designee will assess the situation and contact the Human Resource Department or Facility Director for further direction. If a staff member is suspected of selling drugs, it will be reported to the Human Resource Department or Facility Director for further direction. Staff member will complete a report for the occurrence and give to the Director prior to leaving for the day. Facility Director will initiate an investigation of allegations. A decision on continued employment will be pending investigative findings. The policy and procedure for reporting unusual incidents of selling or use of illicit drugs on the premises by staff or a client will be reviewed during staff meeting on 3/10/20. Staff members will sign attendance sheet for the Policy review. |
709.34 (a) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(3) Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
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Observations
During a licensing inspection conducted on January 13-15, 2020, the project ' s policy and procedure manual failed to develop and implement procedures in responding to death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Policy 709.34 (a) (3) Gaudenzia DRC, Inc. maintains a comprehensive policy that details all necessary steps to be taken in case of death, suicide, attempted suicide or serious injury due to trauma or unusual circumstances. This plan is reviewed and approved by the contracted Psychiatrist. Procedures of Reporting of Unusual Incidents ? Death or serious injury due to trauma, suicide, medication error or unusual circumstances. 1. Upon learning of death or serious injury due to trauma, suicide, medication error or unusual circumstances, the first staff member to respond shall be required to take these steps.
2. The first operations staff to respond to the report shall be required to:
- Call for help/backup (911)
Preserve and protect any crime scene until appropriate steps can be taken to collect any evidence;
3. A summation statement will be entered into the client record regarding the
circumstances surrounding the suicide, death or unusual circumstance. The
statement will be included within the Discharge Summary.
4. The Program Director will notify the following persons of the client suicide/death/traumatic event/medication error/unusual incident:
A. Facility Director
B. Referral Source (i.e. CBH, BHSI) and DDAP
C. Family/next of kin
5. The Program Director will complete a Significant Incident Report and submit it to
the referral source (i.e. CBH, BHSI) and DDAP
The policy and procedure for reporting unusual incidents of selling or use of illicit drugs on the premises by staff or a client will be reviewed during staff meeting on 3/3/20. Staff members will sign attendance sheet for the Policy review.
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709.34 (a) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(4) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
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Observations
During a licensing inspection conducted on January 13-15, 2020, the project ' s policy and proceduremanual failed to develop and implement procedures in responding to significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
PLAN OF CORRECTION: Policy 709.34.(a) (4) Outpatient Evacuation Procedures
1. When notified of an impending or actual emergency or disaster, either by alarm or verbal communication, the nature of the emergency or disaster will dictate what the evacuation procedure will be chosen.
2. In the event of a fire, the staff member on duty will ensure that all occupants of the building vacate the premises via posted emergency exit routes and assemble in the designated area.
3. The staff member in charge will ensure that all occupants have been evacuated. A count will be taken at the assembly area to account for all persons.
4. If it is determined that the facility cannot be re entered, the staff in charge will contact the Outpatient Director and advise him/her of the situation.
5. The Outpatient Director will contact the Facility Director and a decision to close the Outpatient Program until further notice will be made. This decision will be conveyed to the staff on duty by the Outpatient Director.
6. If Outpatient Clinical Services is interrupted for more than 24 hours, a Significant Incident Report will be written by the Outpatient Program Director and sent to Single County Authority and DDAP within 24 hours after the interruption of services.
7. Residential facilities will be notified of the Outpatient closure and contacted when the Gaudenzia DRC Outpatient program reopens.
The policy and procedure for reporting disruption of services due to disaster which closes the facility for more than 24 hours has been written and identified as Policy 709.34 (a) (4,) as required per state regulations, by the Outpatient Director. It will be revewed by the Outpatient Director during Outpatient staff meeting on 3/10/20. Staff members will sign attendance sheet for the Policy review. |
709.34 (a) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(5) Theft, burglary, break-in or similar incident at the facility.
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Observations
During a licensing inspection conducted on January 13-15, 2020, the project ' s policy and procedure manual failed to develop and implement procedures in responding to theft, burglary, break-in or similar incident at the facility.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Policy 709.34 (a) (5) Gaudenzia DRC, Inc. maintains a comprehensive policy that details all necessary steps to be taken in case of theft, burglary, break-in or similar incident at the facility. Procedures: 1. Upon learning of theft, burglary, break-in or similar incident within the facility, or on the facility grounds, the first staff member to respond shall be required to take these steps.
2. The first operations staff to respond to the report shall be required to:
- Call for help/backup
- Call (911) and make a police report
Preserve and protect any crime scene until appropriate steps can be taken to collect any evidence;
3. A facility incident report will be written by staff regarding the circumstances surrounding the unusual incident. The statement will be given to the Program Director or designee.
4. The Program Director will complete a Significant Incident Report and submit it to the referral source (i.e. CBH, BHSI) and DDAP within 24 hours
The policy and procedure for reporting theft, burglary, break-in or similar incidents within facility will be reviewed during staff meeting on 3/10/20. Staff members will sign attendance sheet for the Policy review. |
709.34 (a) (6) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
During a licensing inspection conducted on January 13-15, 2020, the project ' s policy and procedure manual failed to develop and implement procedures in responding to event at the facility requiring the presence of police, fire or ambulance personnel.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Policy 709.34 (a) (6) Gaudenzia DRC, Inc. maintains a policy that details the necessary steps to be taken in case of the presence of police, fire or ambulance personnel at the facility. Reporting procedures: In the event that a participant needs emergency transportation via ambulance, staff will call 911 for Police, Fire and/or Emergency Medical Response, which provides ambulance services to area hospitals and Crisis Response Centers. The staff on duty will document the time Police, Fire or Emergency was called; the time they arrived; who/what the response was for; and the time of the departure; the hospital the client was transported to. The report will be given to the Program Director. The Program Director will complete a Significant Incident Report and submit it to the referral source (i.e. CBH, BHSI) and DDAP within 24 hours. The policy and procedure for reporting Police, Fire, and/or Emergency Medical Response has been written and identified as Policy 709.34 (a) (6) as required per state regulations, by the Outpatient Director. The policy and procedure for reporting Police, Fire, and/or Emergency Medical Response will be revewed during staff meeting on 3/10/20. Staff members will sign attendance sheet for the Policy review. |
709.34 (a) (7) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(7) Fire or structural damage to the facility.
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Observations
During a licensing inspection conducted on January 13-15, 2020, the project ' s policy and procedure manual failed to develop and implement procedures in responding to fire or structural damage to the facility.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Policy 709.34 (a) (7) Fire and Structural Damage -Gaudenzia DRC, Inc. maintains a policy that details the necessary steps to be taken in responding to fire or structural damage in the facility. Procedures: 1. When notified of an actual emergency fire (via smoke detector or fire alarm) or structural damage (via alarm or verbal communication) evacuation procedures will be immediately implemented.
2. In the event of a fire, the staff member on duty will dial 911 and ensure that all occupants of
the building vacate the premises via posted emergency exit routes and assemble in the designated area.
3. The staff member in charge will ensure that all occupants have been evacuated. A count will be taken at the assembly area to account for all persons.
4. If it is determined by the Philadelphia Fire Department that the facility is not structurally sound or determines the building is not safe to be re entered, the staff in charge will contact the Outpatient Director and advise him/her of the situation.
5. The Outpatient Director will contact the Facility Director and the Outpatient Program will be closed until further notice. This decision will be conveyed to the staff on duty by the Outpatient Director.
6. If Outpatient Clinical Services is interrupted for more than 24 hours, a Significant Incident Report will be written by the Outpatient Program Director and sent to Single County Authority and DDAP within 24 hours after the interruption of services.
7. Residential facilities will be notified of the Outpatient closure and contacted when the Gaudenzia DRC Outpatient program reopens.
The Program Director will complete a Significant Incident Report and submit it to the referral source (i.e. CBH, BHSI) and DDAP within 24 hours. The policy and procedure for responding to fire or structural damage to the facility has been written and identified as Policy 709.34 (a) (7,) as required per state regulations, by the Outpatient Director. The policy and procedure for responding to fire or structural damage at the facility will be reviewed by the Outpatient Director during Outpatient staff meeting on 3/10/20. Staff members will sign attendance sheet for the Policy review. |
709.34 (a) (8) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(8) Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
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Observations
During a licensing inspection conducted on January 13-15, 2020, the project ' s policy and procedure manual failed to develop and implement procedures in responding to an outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Policy 709.34 (a) (8) Gaudenzia DRC, Inc. maintains a policy that details the necessary steps to be taken in responding to an outbreak of a contagious disease requiring Centers for Disease Control notification. The Gaudenzia DRC Medical staff will refer the client to Emergency Room foe evaluation. The medical staff will review discharge documentation. If a contagious disease has been identified, the Centers for Disease Control (CDC) will receive notification from the facility physician. The Program Director will complete a Significant Incident Report and submit it to the referral source (i.e. CBH, BHSI) and DDAP within 24 hours.
The policy and procedure for reporting contagious disease to the Centers for Disease Control will be reviewed during staff meeting on 3/10/20. Staff members will sign attendance sheet for the Policy review |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
During a licensing inspection conducted on January 13-15, 2020, the facility failed to provide preliminary treatment plans according to the Projects policy and procedure manual. The policy and procedure manual indicated a preliminary treatment plan would be developed during the intake process. After review of client records, it was determined the preliminary treatment plan was not developed during intake in four of seven client records.
Client # 3 was admitted on November 11, 2019 and was still active at the time of the inspection. A treatment plan was not developed until December 5, 2019.
Client # 4 was admitted on September 10, 2019 and was still active at the time of the inspection. A treatment plan was not developed until October 10, 2019.
Client # 5 was admitted on May 10, 2019 and discharged on November 15, 2019. A treatment plan was not developed until August 6, 2019.
Client # 6 was admitted on May 22, 2019 and discharged on November 29, 2019. A treatment plan was not developed until August 16, 2019.
These findings were reviewed with facility staff during the licensing inspection
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Plan of Correction
POLICY 709.51.b.7 - PRELIMINARY TREATMENT PLAN
The Initial Treatment Plan shall be completed upon completion of the intake process by the Counselor conducting the intake, within the participant's first 72 hours of treatment.
A specific Initial Treatment Plan form shall be used outlining three initial general goals including, but not limited to:
To complete orientation process.
Acknowledge powerlessness over addiction.
Commit to positive recovery oriented change behaviors.
The Preliminary Treatment Plan for client #3 was completed on 9/9/19 at Level 2 (IOP). IOP was successfully completed on 11/11/19 and Level 1 treatment services began. It has been uploaded into Avatar. The Preliminary Treatment Plan for client #4 was completed on 9/10/19. It has been uploaded into Avatar. The Preliminary Treatment Plan for client #5 was completed on 5/10/19. It has been uploaded into Avatar. The Preliminary Treatment Plan for client #6 was completed on 5/22/19. It has been uploaded into Avatar. Intake Supervisor will review Preliminary Treatment Plans completed by Intake Assessment Department. Intake Supervisor will ensure that Preliminary treatment plans are entered into electronic health record (Avatar) staff and participant signatures. The Policy on Preliminary Treatment Plan will be reviewed with the Intake Department on 3/3/20. Intake staff will sign attendance sheet for the Policy and Procedures on |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
During a licensing inspection conducted on January 13-15, 2020, the facility failed to document treatment and rehabilitation plan updates within the regulatory timeframe of sixty days in three of seven client records reviewed.
Client # 1 was admitted on August 28, 2019 and was still active at the time of the inspection. An initial treatment and rehabilitation plan was developed on August 28, 2019. A treatment and rehabilitation plan update was to occur on October 28, 2019 and December 28, 2019. The next treatment and rehabilitation plan documented occurred on January 13, 2020.
Client # 4 was admitted on September 10, 2019 and was still active at the time of the inspection. An initial treatment and rehabilitation plan was developed on October 10, 2019. A treatment and rehabilitation plan update was to occur on December 10, 2019, but at the time of the inspection a treatment and rehabilitation plan update had not been completed.
Client # 5 was admitted on May 10, 2019 and was discharged on November 15, 2019. An initial treatment and rehabilitation plan was developed on August 16, 2019. A treatment and rehabilitation plan update was to occur on October 16, 2019, but an treatment and rehabilitation plan update was not completed prior to discharge.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Outpatient Clinical Supervisor/Program Director will review treatment plan updates due during weekly supervision. There will be supervisions had with the respective counselors for Client #1, Client # 4, and Client #5 regarding treatment plan updates that were not completed within sixty (60) days.
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709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
During a licensing inspection conducted on January 13-15, 2020, the facility failed to provide counseling services according to the individual treatment and rehabilitation plan in five of seven records reviewed.
Client # 3 was admitted on November 11, 2019 and was still active at the time of the inspection. The treatment and rehabilitation plan dated December 5, 2019 indicated individual sessions weekly. The client progress notes, and record of service only documented individual sessions to have occurred on November 14, 2019 and January 10, 2020.
Client # 4 was admitted on September 10, 2019 and was still active at the time of the inspection. The treatment and rehabilitation plan dated October 10, 2019 indicated individual sessions weekly. The client progress notes, and record of service only documented individual sessions to have occurred on November 7, 4, 21, December 12, 2019, January 2, and 13, 2020.
Client # 5 was admitted on May 10, 2019 and was discharged on November 15, 2019. The treatment and rehabilitation plan dated August 6, 2019 indicated individual sessions monthly. The client progress notes, and record of service only documented individual sessions to have occurred on July 16, 30, and August 27, 2019.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
PLAN OF CORRECTION: POLICY 709.24 (a) (3) - PLAN FOR THE COORDINATION OF TREATMENT & REHABILITATION SERVICES ... Specific details related to the documentation of services and the use of chart forms are provided in the Participant Records section of this manual. The procedures and steps applicable to these services are as follows: #12. Therapy Notes: The Counselor shall provide regular individual, family and group sessions as determined by the Counselor in consultation with the Clinical Supervisor and Medical Director and as noted on the individualized treatment plan. A progress note shall be written by the Counselor, Nurse or other staff person documenting significant participant contact for therapy sessions, health education sessions and phone calls. Notes shall reflect objective data, an assessment of that data and strategic action responses to the assessment (DAP). Progress Notes provide a record of what happened to the participant in treatment and indicate progression or regression. Notes shall be completed the same day as the contact with the participant and shall be legible.Clinical Supervisor will provide supervision to Client #3 Outpatient Counselor regarding documenting No Shows and rescheduled individual sessions within Avatar. Clinical Supervisor will provide supervision to Outpatient Counselor for Client #4 regarding documenting No Shows and rescheduled individual sessions within Avatar. Clinical Supervisor will provide supervision to Outpatient Counselor for Client #5 regarding documenting No Shows and rescheduled individual sessions within Avatar. Clinical Supervisor will complete these supervisions by 3/5/20. Clinical Supervisor will complete random chart audits weekly and to ensure that the documentation of individual treatment services, no shows and session rescheduling are being recorded in the electronic health record by counselors. The policy on THE COORDINATION OF TREATMENT & REHABILITATION SERVICES will be reviewed by the Outpatient Director with Outpatient staff during the 3/17/20 Outpatient staff meeting. Staff members will sign attendance sheet for the Policy review. |
709.93(a)(7) 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:
(7) Client-related correspondence.
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Observations
During a licensing inspection conducted on January 13-15, 2020 the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in two of seven client records.
Client # 3 was admitted on November 11, 2019 and was still active at the time of the inspection. Receipts for lab work dated January 10, 2020, December 5, November 21, 14, and 17 2019, were available in the client record without a consent to release form.
Client # 4 was admitted on September 10, 2019 and was still active at the time of the inspection. Receipts for lab work dated January 02, 2020, December 12, November 21, 14, 7, October 31, 24, 17, 10, 03, September 29, and 19, 2019 were available in the client record without a consent to release form.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Policy 709.28-c No information, whether written or verbal, will be requested from or disclosed to any outside source without the informed voluntary written consent of the participant. The Counselor, Nurse or designated program staff will review and complete the Consent to Release Information with the participant as needed. After review of the orientation materials and an explanation of the project's confidentiality policy, the Counselor conducting the intake interview will ask the participant to sign Consents to Release Information for the following: 6. Urine Drug Screen laboratories Client #3 Consent forms for Urine Drug screens were completed during Intake on 9/9/19. They have been uploades into Avatar. Client #4 Consent forms for Urine Drug screens were completed during Intake on 9/9/19. They have been uploades into Avatar. |
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
During as licensing inspection conducted on January 13-15, 2020, the facility failed to provide case consultations according to the facility ' s policy and procedure manual in five of seven records reviewed. The facility policy and procedure manual indicated a consultation to occur every ninety days and then sixty days thereafter.
Client # 1 was admitted on August 28, 2019 and was still active at the time of the inspection. A case consultation was due no later than November 28, 2019, there was no documentation of any case consultation in the client record.
Client # 2 was admitted on September 25, 2019 and was still active at the time of the inspection. A case consultation was due no later than December 25, 2019, there was no documentation of any case consultation in the client record.
Client # 4 was admitted on September 10, 2019 and was still active at the time of the inspection. A case consultation was due no later than December 10, 2019, there was no documentation of any case consultation in the client record.
Client # 5 was admitted on May 10, 2019 and discharged on November 15, 2019. A case consultation was due no later than August 10, 2019, there was no documentation of any case consultation in the client record.
Client # 6 was admitted on May 22, 2019 and discharged on November 29, 2019. A case consultation was due no later than August 22, 2019, there was no documentation of any case consultation in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Policy 709.53 a. 8 -Participants in treatment will have a documented case consultation within 90 days. Documentation of case consultations will be done bi-monthly (every 60 days) after 90 days. Provisions should be made for more frequent case consultation if necessitated by participant response, or lack of response, to treatment. Case consultations for Client #1 were completed effective 11/25/19 & 1/23/20 as paper records and not available for electronic chart audit. Case consultations for Client #2 was completed as a paper record on 12/24/19 and was available for electronic chart audit. Case consultations for Client #4 was completed as a paper record effective 12/3/19 and was not available for electronic chart audit. Case consultations for Client #5 were completed as paper records effective 7/12/19 & 9/10/19 but were not available for electronic chart audit. Case consultations for Client #6 were completed as paper records effective 7/24/19 & 9/17/19 but were not available for electronic chart audit. The Clinical Supervisor uploaded all of the aforementioned case consultations into Avatar. The Clinical Supervisor will complete a supervision with outpatient counselors on how to upload documents into Avatar. Clinical Supervisor will complete a supervision with outpatient counselors regarding the use of the Case Consultation form in Avatar. The policy on Case Consultation will be reviewed by the Outpatient Director with Outpatient staff during the 3/17/20 Outpatient staff meeting. Staff members will sign attendance sheet for the Policy review. |