INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the June 10, 2010 licensure renewal inspection. The follow-up inspection was conducted on December 2, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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 December 28, 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
At the time of the follow-up review on December 2, 2010, it was not possible for the licensing specialist to determine if the facility followed the original plan of correction and was in compliance due to the fact that the facility ' s 2010 training year still in progress, and 25 clock hours of annual training for each counselor is not yet due to be completed. The facility must resubmit original plan of correction.
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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. |
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 and an interview with a counselor, the facility failed to document a physical examination in three of seven client records.
The findings include:
Seven client records were reviewed on December 2, 2010 for documentation of 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 and 5.
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 8/27/10, but a physical examination was not documented at the time of review on 12/2/10.
Client #4 was admitted to the program on 9/22/10, but a physical examination was not documented at the time of review on 12/2/10.
Client #5 was admitted to the program on 9/24/10, but a physical examination was not documented at the time of review on 12/2/10.
An interview with a counselor on December 2, 2010 confirmed that the identified client records did not contain a physical examination documented within the first week of admission.
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Plan of Correction
Another in-service training will be facilitated on 12/17/10 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 to Program Director weekly. |
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 and an interview with a counselor, the facility failed to document a treatment plan update in six of seven client records.
The findings include:
Seven client records were reviewed on December 2, 2010 for documentation of a treatment plan update. The facility did not document a treatment plan update, as per facility policy, in client records # 1, 2, 3, 4, 6 and 7.
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 #1, the treatment plan update documented on 10/30/10 did not include an assessment of progress.
In client record #2, the treatment plan updates documented on 9/30/10 and 10/30/10 did not include an assessment of progress.
In client record #3, the treatment plan update documented on 10/10/10 did not include an assessment of progress. Additionally, a treatment plan update was required 30 day after the one documented on 10/10/10, but at the time of review one had not been documented.
In client record #4, the treatment plan update documented on 10/24/10 did not include an assessment of progress. Additionally, a treatment plan update was required 30 day after the one documented on 10/24/10, but at the time of review one had not been documented.
In client record #6, the treatment plan update documented on 10/20/10 did not include an assessment of progress. Additionally, a treatment plan update was required 30 day after the one documented on 10/20/10, but at the time of review one had not been documented.
In client record #7, the treatment plan update documented on 10/30/10 did not include an assessment of progress.
An interview with a counselor on December 2, 2010 confirmed that the identified client records did not contain treatment plan updates documented in accordance with facility policy.
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Plan of Correction
Another in-service will be facilitated by Supervisors, on 12/17/10 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. |
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 and an interview with a counselor, the facility failed to document the reason(s) for missed medication doses for five clients.
The findings include:
The client medication administration log was reviewed on December 2, 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 #1 was prescribed Citalopram 20mg, 1 tablet daily.
During the month of November 2010 this medication was not administered. The medication administration record did not document the reason(s) why this medication was not administered as prescribed.
Client #5 was prescribed Citalopram 20mg, 1 tablet daily.
During the month of November 2010 this medication was not administered. The medication administration record did not document the reason(s) why this medication was not administered as prescribed.
Client #6 was prescribed Omeprazole 10mg, 1 capsule daily.
During the month of November 2010, this medication was administered only on November 1, 2, 3 and 5. The medication administration record did not document the reason(s) why this medication was not administered as prescribed.
Client #7 was prescribed Chlorpromazine 200mg, 1 at bedtime.
During the month of November 2010 this medication was not administered. The medication administration record did not document the reason(s) why this medication was not administered as prescribed.
Client #7 was prescribed Lisinopril 20mg, 1 in the morning.
During the month of November 2010 this medication was not administered. The medication administration record did not document the reason(s) why this medication was not administered as prescribed.
Client #8 was prescribed Seroquel 25mg, 1 tablet at bedtime.
During the month of November 2010, this medication was administered only on November 1, 2, 3, 4, 5, 6, 22, 23, 24, 25 and 26. The medication administration record did not document the reason(s) why this medication was not administered as prescribed.
An interview with a counselor on December 2, 2010 confirmed that the medication administration log did not indicate the reason(s) why medications were not administered as prescribed.
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Plan of Correction
Another in-service will be facilitated by Supervisors, on 12/17/10 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. |
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 the facility ' s follow-up log and an interview with a counselor, the facility failed to document follow-up information for client discharged from the facility.
The findings include:
The facility ' s follow-up log was reviewed on December 2, 2010 for follow-up information. The facility was required to document follow-up information within seven days after discharge, as per facility policy. The last completed follow-up information was documented in July 2010.
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. "
An interview with a counselor confirmed that in 2010 clients were discharged in August, September, October and November, but follow-up information had not been completed.
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Plan of Correction
Another in-service training will be facilitated on 12/17/10 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. |