INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 10, 2010 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 and a plan of correction is due on July 10, 2010.
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Plan of Correction
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on the review of personnel training records and an interview with the Training Manager, the facility failed to document at least 25 clock hours of training annually in one of one personnel records.
The findings include:
Four personnel training records were reviewed on May 7, 2010. Of the four records reviewed, one was identified as a counselor and required at least 25 clock hours of training for the 2009 training year. The facility did not document at least 25 hours of training for personnel # 3. The training record for personnel # 3 contained 14 hours of training for the 2009 training year.
An interview with the training Manager was conducted on May 7, 2010. The Training Manager confirmed that only 14 hours of training had been documented for personnel # 3.
This is a repeat citation. The facility did not document at least 25 hours of annual training for all counselors during the licensing inspection conducted on June 9, 2009.
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Plan of Correction
The Staff met with Program Director during the Week of June 14, 2010 to discuss and schedule Trainings to meet Annual Staff Training requirements. All Staff have been scheduled to attend trainings throughout the calendar year to meet requirements. Copies of training certificates and evaluations will be sent to the Corporate Training institute monthly to document compliance with Staff Training requirements. Program Director will ensure that all Clinical Staff will have full Training Hours required by Program. Program Director will utilize a "Training Tracking Form" to monitor compliance. During the current training year Counselor #3 has completed 30 hours of Clinical Supervision Trainings on 3/12/10 and 6 hours of PCPC training on 3/29/10 to date. (6/26/10) |
709.51(b)(3)(ii) LICENSURE Drug & Alcohol History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on the review of client records, the facility failed to document a drug and alcohol history in five of six client records.
The findings include:
Six client records were reviewed on June 10, 2010. All six records required a drug and alcohol history. The facility failed to document a comprehensive drug and alcohol history, as per facility policy, in client records # 2, 3, 4, 5 and 6.
The Gaudenzia policy titled " PROCEDURE FOR INTAKE DOCUMENTATION OF HISTORIES " states:
" Drug & Alcohol History: Counselor or nurse performing the intake interview shall document the substances used, the patterns of use, and prior treatment episodes. The client's perception of the physical, mental, and social effects of his addiction, as well as any family addiction history shall be noted. "
In records # 2, 3 and 4 the drug and alcohol histories did not include substances used, patterns of use, and prior treatment episodes.
In record #5, the drug and alcohol history did not include patterns of use.
In record #6, the drug and alcohol history did not include prior treatment episodes.
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Plan of Correction
All Clients will have updated Biopsychosocial Histories documenting drug and alcohol history, i.e. substances used, patterns of use, prior treatment episodes and the client's perception of physical, mental, and social effects of the addiction, as well as family addiction history. An in-service facilitated by Supervisors, was held Friday, June 11, 2010 to address Biopsychosocial Histories. Counselors will review charts to identify Biopsychosocial Histories that fail to meet licensing standards and correct deficiencies. Senior Counselor will monitor compliance bi weekly during individual supervision sessions, and monthly through our Continuous Quality Improvement program. Senior Counselor will report findings for three months in CQI. Program Director will oversee this Plan of Correction. (6/26/10) |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on the review of client records, the facility failed to document a physical examination in four of six client records.
The findings include:
Six client records were reviewed on June 10, 2010. All six records required a physical examination. The facility did not document a physical examination within the first week of admission, as per facility policy, in client records # 2, 4, 5 and 6.
The Gaudenzia policy titled " PLAN FOR THE COORDINATION OF TREATMENT & REHABILITATION SERVICES " States:
Upon admission, residents shall have a physical examination performed the first week of admission. The physical examination will assure that a client is free from communicable diseases or any other medically related concern that would pose a significant obstacle to treatment. In cases where a client has received a verifiable physical examination within one month prior to admission, the program Medical Director or his/her designee shall perform an examination comprised of taking and recording of vital signs and asking the client if significant changes have occurred since his/her last exam.
Client # 2 was admitted to the program on 3/9/10, but the physical examination was dated 1/19/10.
Client # 4 was admitted to the program on 1/7/10, but the physical examination was dated 11/24/09.
Client # 5 was admitted to the program on 1/12/10, but the physical examination was dated 11/12/09.
Client # 6 was admitted to the program on 1/14/10, but the physical examination was dated 11/13/09.
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Plan of Correction
An in-service training was facilitated on 6/11/10 to instruct Staff on Physical Examination policy. All Clients will have verifiable physical examinations within one month prior to admission or a physical examination will be performed during the first week of admission. Referring agency will be informed physicals must be within thirty days of admission to Re-Entry Program. In the event a client is admitted without a verifiable physical examination within one month, a physical examination will be performed by Abbotsford ? Falls Family Practice, 4700 Wissahickon Avenue, Suite #119, Philadelphia, PA 19144 within one week. Senior Counselor will monitor compliance for physical examination documents during client admission process, counselor supervision, and chart auditing process. Senior Counselor will report findings for three months in CQI. Program Director will oversee this Plan of Correction. (6/26/10) |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on the review of client records, the facility failed to document a treatment plan to include type and frequency of treatment and rehabilitation services in six of six records.
The findings include:
Six client records were reviewed on June 10, 2010. All six records required documentation of type and frequency of treatment and rehabilitation services. The facility did not document a treatment plan to include type and frequency of treatment services, as per facility policy, in client records # 1, 2, 3, 4, 5 and 6.
The facility ' s policy titled "PROCEDURE FOR INDIVIDUAL TREATMENT & REHABILITATION PLAN" states:
" Included in the action plan will be a statement of the type (individual / group / family therapy, health education, etc.) and frequency (daily, 2-3 x weekly, once, ongoing, etc.) of service in which the client will be involved. "
In record #1, the treatment plan documented on 4/26/10 did not include type and frequency of treatment and rehabilitation services.
In record #2, the treatment plan documented on 3/12/10 did not include type and frequency of treatment and rehabilitation services.
In record #3, the treatment plan documented on 3/22/10 did not include type and frequency of treatment and rehabilitation services.
In record #4, the treatment plan documented on 1/10/10 did not include type and frequency of treatment and rehabilitation services.
In record #5, the treatment plan documented on 1/13/10 did not include type and frequency of treatment and rehabilitation services.
In record #6, the treatment plan documented on 1/14/10 did not include type and frequency of treatment and rehabilitation services.
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Plan of Correction
An in-service facilitated by Supervisors, was held Friday, June 11, 2010 to address Treatment and rehabilitation service plan documentation of type and frequency of treatment and rehabilitation services. Ongoing training will be provided by the Gaudenzia Training Institute. Treatment and rehabilitation service plans will be reviewed by Supervisors bi weekly during individual supervision sessions, and monitored monthly through our Continuous Quality Improvement program. Forms will be reviewed by Continuous Quality Improvement Committee. (6/26/10) |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on the review of client records, the facility failed to document a treatment plan update in five of six client records.
The findings include:
Six client records were reviewed on June 10, 2010. All six records required a treatment plan update. The facility did not document a treatment plan update, as per facility policy, in client records # 2, 3, 4, 5 and 6.
The facility ' s policy titled " Treatment Plan Reviews " states:
The Counselor shall complete a treatment plan review and update 30 days after the date of the original individual treatment plan for residential, (and every 30 days thereafter), 14 days after the date of the original individual treatment plan for short-term (and every 14 days thereafter) and 60 days after for outpatient and every 60 days thereafter. This review shall include an assessment of the client's progress with the goals identified on the treatment plan along with a specific indication of how each goal has been impacted.
In client record #2, the treatment plan update documented on 5/12/10 did not include an assessment of progress.
In client record #3, the treatment plan was dated 3/22/10, but a treatment plan update was not documented at the time of inspection on 6/10/10.
In client record #4, the treatment plan updates documented on 2/10/10 and 3/10/10 did not include an assessment of progress.
In client record #5, the treatment plan updates documented on 2/13/10 and 3/13/10 did not include an assessment of progress.
In client record #6, the treatment plan updates documented on 2/14/10 and 3/14/10 did not include an assessment of progress.
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Plan of Correction
An in-service facilitated by Supervisors, was held Friday, June 11, 2010 to address Treatment and rehabilitation service plan update review of progress on previously stated goals. Ongoing training will be provided by the Gaudenzia Training Institute. Treatment and rehabilitation service plan updates will be reviewed by Supervisors during individual supervision sessions, and monitored through our Continuous Quality Improvement program. Forms will be reviewed by Continuous Quality Improvement Committee. (6/26/10) |
709.53(a)(2) LICENSURE Medication records
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:
(2) Medication records.
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Observations
Based on the review of client medication administration records, the facility failed to document missed medication doses in five client records.
The findings include:
The client medication administration log was reviewed on June 10, 2010. The client medication administration records indicated clients had not received their medications as prescribed. The medication administration records did not document the reason(s) why medications were not received as prescribed.
The Facility ' s policy titled " MEDICATION CONTROL - MEDICATION ADMINISTRATION " states:
" If a client is unavailable or refuses to take medication at the correct time, the Nurse shall circle and initial the med sheet and document in the comments section the reason the medication was not given. "
Client # 7 was prescribed Diphenhydramine 50mg, 1 capsule at bedtime.
During the month of June 2010 this medication was not administered. The medication administration record did not document the reason(s) why this medication was not administered.
Client # 7 was prescribed Risperidone 2mg, 1 tablet at bedtime.
During the month of June 2010 this medication was not administered. The medication administration record did not document the reason(s) why this medication was not administered.
Client # 8 was prescribed Amitriptyline 25mg, 1 tablet at bedtime.
During the month of June 2010 this medication was not administered. The medication administration record did not document the reason(s) why this medication was not administered.
Client # 9 was prescribed Cymbalta 30mg, 1 capsule daily.
During the month of June 2010 this medication was not administered on 6/1/10, 6/2/10, 6/6/20 and 6/7/10. The medication administration record did not document the reason(s) why this medication was not administered.
Client # 10 was prescribed Seroquel 150mg, 1 tablet daily.
During the month of June 2010 this medication was not administered on 6/1/10, 6/2/10, 6/5/20, 6/6/20, 6/7/20, 6/8/20, and 6/9/20. The medication administration record did not document the reason(s) why this medication was not administered.
Client # 11 was prescribed Seroquel 50mg, 1 tablet at bedtime.
During the month of June 2010 this medication was not administered. The medication administration record did not document the reason(s) why this medication was not administered.
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Plan of Correction
An in-service facilitated by Supervisors, was held Friday, June 11, 2010 to address Medication Record documentation of missed dosing due to unavailability or refusal. If a client is unavailable for, or refuses mediation a ® will be recorded in the Medication Record and an entry made in the Communication Log to alert the client's counselor of non-compliance. Additionally, the importances of recording dates of medication prescription were reviewed. Medication Records will be monitored by supervision staff during individual supervision sessions, and monitored through our Continuous Quality Improvement program. (6/26/10 |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow-up information in three of three client records.
The findings include:
Six client records were reviewed on June 10, 2010. Of the six records reviewed, three had been discharged, and documentation of follow-up was required. The facility did not document follow-up information within seven days after discharge, as per facility policy, in client records # 4, 5 and 6.
The facility ' s policy titled " Follow Up " states:
" Within seven (7) days of the date of a referral appointment made for a client leaving treatment, the referral shall be contacted by the Counselor to determine if the client kept the initial appointment and if the referral was appropriate. In the case of a client ending treatment without a referral appointment (ASA, Therapeutic Discharge, Completion who refuses further treatment), the client shall be contacted directly by the counselor or supervisor ' s designee to determine the client ' s well-being and to maintain the opportunity for re-admission should circumstances warrant it as necessary and appropriate. Information shall be kept in the follow up log binder. "
Client #4 was discharge on 4/6/10, but the follow-up log binder did not include follow-up information for this client.
Client #5 was discharge on 4/12/10, but the follow-up log binder did not include follow-up information for this client.
Client #6 was discharge on 4/9/10, but the follow-up log binder did not include follow-up information for this client.
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Plan of Correction
An in-service training was facilitated on 6/11/10 to instruct Staff on how to document follow-up within seven days after Discharge. Clinical and House Management Staff have been designated to facilitate follow-ups to ensure that all individuals leaving the Program will have a follow up contact within seven days of discharge. Senior Counselor will follow up monthly with designated Staff Members and review follow-up book to ensure that policy is followed. (6/11/10) |