INITIAL COMMENTS
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This report is a result of an on-site licensure inspection conducted on June 1, 2012 by staff from the Division of Drug and Alcohol Program Licensure.
Based on the findings of the on-site inspection, Gaudenzia, Inc. Re-Entry House was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
The following deficiencies were identified during this inspection:
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Plan of Correction
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to document an individual training plan in accordance with facility policy in two of two records.
The findings include:
The project policy states: "In January of each year, the Program Director, in conjunction with the Supervisor, will conduct needs assessments, via individual training plan forms for all employees, to determine what topics and areas of training should be provided during the coming year."
On May 9, 2012, employee # 1 and 2 ' s personnel record was reviewed.
The project failed to develop an individual training plan annually in accordance with policy.
Employee # 1 has been the Project Director since 1988.
Per policy, training plans will be conducted in January of each year.
The facility failed to document an individual training plan in January for employee # 1.
Employee # 2 was hired 3/1/2010.
Per policy, training plans will be conducted in January of each year.
The facility failed to document an individual training plan in January for employee # 2.
The findings were reviewed with the human resources staff.
This is a repeat citation. The Project was previously cited for noncompliance with this standard during the 2011 licensure inspection.
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Plan of Correction
The Training Department will ensure that an individual training plan is developed and documented for all employees within required timeframes. A reminder of the January 31st deadline for completion will be forwarded to all Managers during the 1st week of December. In addition, the Training Department will coordinate with the Executive Assistant to ensure that development of an Individual Training Plan for the Project Director is a specific agenda item during the Project Director's meeting with the Chairman of the Board during the month of December. A current, signed Individual Training Plan is presently in the Project Director's file." Individual Training Plans will be completed for all employees by January 31st, 2013 as per our policy. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to document fire extinguisher training upon staff employment.
The findings include:
On May 9, 2012, two employee records were reviewed to verify that staff were instructed in the use of the fire extinguishers upon employment.
The facility did not document fire extinguisher training upon employment in one out of two personnel records reviewed, # 4.
Employee # 4 was hired 5/9/11, but verification of fire extinguisher training was not documented until 5/26/11.
The Facility Director confirmed the findings.
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Plan of Correction
The Senior Counselor and Senior House Manager will ensure that all personnel are trained to perform assigned tasks during emergencies, and shall instruct all staff in the use of the fire extinguishers within seven days of staff employment. This will be monitored by the Program Director. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
The findings include:
On May 9, 2012, two employee records were reviewed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies.
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The facility did not document emergency training upon employment in personnel one out of two records reviewed, # 4.
Employee # 4 was hired 5/9/11, but verification of emergency training was not documented until 5/26/11.
The Facility Director confirmed the findings.
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Plan of Correction
The Senior Counselor and Senior House Manager will ensure that all personnel are trained to perform assigned tasks during emergencies, and shall instruct all staff in the use of the fire extinguishers within seven days of staff employment. This will be monitored by the Program Director. |
709.24(a)(3) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based upon a review of the project's Policy & Procedure (P&P) Manual, the project failed to adopt consistent policies for individualized treatment and rehabilitation plans. The facility had policies for treatment plans that were contradictory.
The findings include:
The P&P Manual was reviewed from May 1 - 2, 2012.
The policy titled, "Intake Process/Paperwork" Treatment Plan included the following language:
"The individualized treatment plan shall be completed, approved and signed by the Counselor, Clinical Supervisor and Medical Director(when applicable) within 3-5 client days residential..."
The policy titled, "Individual Treatment Plan" Individual Treatment and Rehabilitation Plan included the following language:
"Completion of the treatment plan will be noted in the counselor's progress note for that day of service, within 3 days of admission (residential)..."
The first policy allows five days to complete the individualized treatment plan while the second policy stipulates it must be completed within three days.
Regarding outpatient facilities, the policy titled, "Individual Treatment Plan" Individual Treatment and Rehabilitation Plan included the following language:
"An individual treatment and rehabilitation plan will be developed with each client after the completion of the client's psychosocial evaluation."
The policy titled, "Intake Process/Paperwork" Treatment Plan included the following language:
"Based on the psychosocial assessment, the Counselor shall formulate an individualized treatment plan ..."The individualized treatment plan shall be completed, approved and signed by the Counselor, Clinical Supervisor and Medical Director (when applicable) ... by the second or third counseling outpatient appointment....."
The policy titled, "Intake Process/Paperwork" Psychosocial Assessment stated:
Upon completion of the psychosocial histories...The assessment shall be submitted promptly ... to the Clinical Supervisor for review and signature ... within 3 individual sessions for outpatient.
The policy titled, "Individual Treatment Plan" Individual Treatment and Rehabilitation Plan included the following language:
"Completion of the treatment plan will be noted in the counselor's progress note for that day of service,... by the third session (outpatient)..."
Each policy relating to the completion of the treatment plans for outpatient contained statements that require the treatment plan be completed in three sessions (regardless of being individual or group) while there are other statements that would indicate that the treatment plan would not be required or allowed to be completed until the third individual session based on the completion of the psychosocial assessment.
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Plan of Correction
The relevant policies in the Gaudenzia Policy and Procedure manual will be revised by the Quality Improvement Director to ensure consistency and clarity, and to meet all relevant State, Accreditation, and Funding requirements. Changes to these policies will be reviewed and approved by the Board of Directors. These changes will be reviewed with clinicians at each facility's staff meetings by the Program Director and/or Program Supervisor in order to ensure full understanding and ongoing compliance. Program Supervisors will monitor timely completion of Individual Treatment Plans as part of regular clinical chart reviews, and the findings of these reviews will be discussed in regular clinical supervision as well as staff meetings and monthly CQI analysis." These policies will be revised and approved by July 31st, 2012.
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709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based upon the review of Administrative documentation, the project failed to have an annual audit of financial activities associated with the project's drug/alcohol abuse services completed upon conclusion of the fiscal year.
The findings include:
Licensing Staff conducted an Administrative Review from May 7 - 9, 2012.
Administrative documentation specified that the fiscal year runs from July 1 to June 30. However, the project's annual fiscal audit was late as it was completed February 20, 2012.
The findings were reviewed during the exit interview for the Administrative Review and were not disputed.
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Plan of Correction
At the most recent Audit Committee meeting, the necessity that all future financial audits must be completed within required timeframes was reinforced with the external independent public accountant. These timeframes were acknowledged by the independent public accountant and recorded in the meeting minutes. The Director of Finance and Accounting will maintain oversight throughout the auditing process to ensure completion in a timely manner." The Financial Audit for Fiscal Year 2011-2012 will be completed within 6 months after the June 30th close of Gaudenzia's fiscal year (by December 31st, 2012) as per Chapter 709.25(a). |
709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records and clinical documentation, the facility failed to obtain an informed and voluntary consent in two of five client records reviewed.
The findings include:
On June 1, 2012, five client records requiring documentation of an informed and voluntary consent were reviewed to ensure compliance with 4 Pa. Code 255.5. The facility failed to adhere to the requirements specified at 4 Pa. Code in two of five records reviewed, specifically client record # 3 and 7.
4 Pa. Code 255.5 states:
Information released to judges, probation or parole officers, insurance company, health or hospital plan or governmental officials, pursuant to paragraphs (1), (2), (4),(7), (8) or subsection (a) of this section, is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following.
(1) Whether the client is or is not in treatment.
(2) Client's prognosis.
(3) The nature of the project.
(4) A brief description of the client's progress.
(5) A short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse.
Client # 3 was admitted to the program on 3/28/12. A signed "Confidential Request to Release Information" form was documented on 3/28/12. The signed "Confidential Request to Release Information" form documented the release of urinalysis results to the client's P.O., which exceeds the limitations of 4 Pa. Code 255.5.
Client # 7 was admitted to the program on 2/24/12. A signed "Confidential Request to Release Information" form was documented on 3/2/12. The signed "Confidential Request to Release Information" form documented the release of urinalysis results to the client's P.O., which exceeds the limitations of 4 Pa. Code 255.5.
The Facility Director confirmed the findings.
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Plan of Correction
The necessary corrections have been made in Client charts #3 and #7. Confidentiality is of utmost importance. An in-service facilitated by the Director, was held Friday, June 8, 2012 to address Confidentiality. Ongoing training will be provided by the Gaudenzia Training Institute quarterly. Consent to release information documents will be reviewed by Supervisors during individual supervision sessions, and monitored through our Continuous Quality Improvement program. Client # 3 and 7 completed new consent to release forms which adheres to 4 Pa. Code 255.5. In addition, moving forward all consent to release forms will adhere to confidentiality regulation 4 Pa. Code 255.5 and only release:
Information released to judges, probation or parole officers, insurance company, health or hospital plan or governmental officials, pursuant to paragraphs (1), (2), (4),(7), (8) or subsection (a) of this section, is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following.
(1) Whether the client is or is not in treatment.
(2) Client's prognosis.
(3) The nature of the project.
(4) A brief description of the client's progress.
(5) A short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse.
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709.28(c)(2) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of client records and clinical documentation, the facility failed to obtain an informed and voluntary consent in one of five client records reviewed.
The findings include:
On June 1, 2012, five client records requiring documentation of an informed and voluntary consent were reviewed to ensure compliance with 28 Pa. Code 709.28 and 42 CFR Part II subpart C subsection 2.31 (b). The facility failed to adhere to the requirements specified at 28 Pa. Code in one of five records reviewed, specifically client record # 3.
28 Pa. Code 709.28 states:
The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
(2) Specific information disclosed.
(3) Purpose of disclosure.
(4) Dated signature of client or guardian.
(5) Dated signature of witness.
(6) Expiration date of the consent.
Client # 3 was admitted to the program on 3/28/12.
On 4/12/12 the facility completed and faxed to a government agency a document titled "Confidential Psychiatric/Psychological Evaluation."
The "Confidential Psychiatric/Psychological Evaluation" form included client # 3's diagnosis, history, medications, treatment recommendations, and frequency of therapy, prognosis, medical history, and the clinician ' s opinion/diagnostic impression.
The facility did not have a Qualified Service Organization Agreement (QSOA) with the government agency nor did the facility obtain an informed and voluntary consent from client # 3 for the release of information.
The Facility Director confirmed the findings.
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Plan of Correction
The necessary corrections have been made in Client chart #3. Confidentiality is of utmost importance. An in-service facilitated by the Director, was held Friday, June 8, 2012 to address Confidentiality. Ongoing training will be provided by the Gaudenzia Training Institute quarterly. Consent to release information documents will be reviewed by Supervisors during individual supervision sessions, and monitored through our Continuous Quality Improvement program. As the information has already been disclosed in client record # 3 moving forward, to ensure future compliance with confidentiality, in particular, 28 Pa. Code 709.28 and 42 CFR Part II subpart C subsection 2.31 (b) all consent to release forms will adhere to confidentiality regulation 28 Pa. Code 709.28.
The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
(2) Specific information disclosed.
(3) Purpose of disclosure.
(4) Dated signature of client or guardian.
(5) Dated signature of witness.
(6) Expiration date of the consent.
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709.32(c)(3) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(3) Inspection of storage areas.
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Observations
Based on a review of the policy and procedure manual, administrative documentation, and a conversation with the head nurse, the facility failed to document inspection of the storage area according to policy.
Findings:
The facility policy states: "The drug storage area and medications shall be inspected by a registered pharmacist per agreement who comes on site at least monthly. The Medication and Drug Storage Inspection form shall be completed monthly by the pharmacist conducting the inspection and by the nurse who accompanies him/her during the inspection."
On June 1, 2012 a physical plant inspection was conducted at approximately 1:30 PM.
Based on a review administrative documentation and a conversation with the head nurse; the facility did not comply with the policy and procedures manual as the pharmacist does not come on site monthly to inspect storage area, rather the storage area inspection is conducted in house by the head nurse.
The head nurse and the Facility Director confirmed the findings.
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Plan of Correction
The relevant policy in the Gaudenzia Policy and Procedure manual has been revised by the Quality Improvement Director removing the specification that a registered pharmacist be involved. Changes to this policy will be reviewed and approved by the Board of Directors. This change will be reviewed with nursing staff at each facility's staff meetings by the Director of Nursing and/or Nurse Manager in order to ensure full understanding and ongoing compliance." This policy revision will be approved by July 31st, 2012. |