INITIAL COMMENTS
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This report is a result of an on-site licensure inspection conducted on May 16, 2011 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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705.1 (3) LICENSURE Gen requirements for residential facilities.
705.1. General requirements for residential facilities.
The residential facility shall:
(3) Comply with applicable Federal, State and local laws and ordinances.
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Observations
Based on observation, and a physical plant inspection, the facility failed to comply with applicable Federal, State and local laws and ordinances.
The findings include:
The city of Philadelphia uses the International Building Code which includes the National Electrical Code (N.E.C.)
The N.E.C. requires that the wiring be installed in a workman like manner and that it be secured within 12 inches of a junction box/electrical box or panel box and a minimum of every four and a half feet thereafter. In addition, armored cable is to be secured to each joist when exposed and it is not to be supported off of piping or ductwork.
A physical plant inspection was conducted on May 16, 2011 at approximately 1:30 PM.
The facility failed to ensure that the electrical wiring located in the basement was installed and secured in accordance with the National Electrical Code (N.E.C.).
Exposed electrical wires were observed throughout the basement area which is used by residents and staff for food and clothing storage, recreation, and laundry.
The facility director, the regional director, and the maintenance man stated that the exposed wiring has not been an issue in the past.
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Plan of Correction
The Director of Operations was informed of the electrical wiring deficiencies identified during the on sight inspection conducted May 16, 2011. An assessment was made to determine how to proceed with correcting the deficiency. Maintenance personal are responsible for making the correction and maintaining compliance. The wring is in the process of being secured within 12 inches of a junction box/electrical box or panel box and a minimum of every four and a half feet thereafter. Additionally, armored cable is being secured to each joist. Regularly scheduled maintenance inspections will be conducted by the maintenance department under the supervision of the Director of Operations and the Director of Maintenance. The facility will be in full compliance by August 31, 2011. |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on observation, and a physical plant inspection, the facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors.
The findings include:
A physical plant inspection was conducted on May 16, 2011 at approximately 1:30 PM.
It was observed during the physical plant inspection that the kitchen walls were marred.
In addition, the walls were marred in bedrooms # 2 and 7, the 3rd floor communal restroom, and the 3rd floor lounge.
The facility director confirmed that the facility could use a paint job; he stated that the facility was on the projects maintenance waiting list.
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Plan of Correction
The Director of Operations and the Director of Maintenance were informed and made an assessment of all painting and maintenance needs. A painter was hired to correct the deficiency and is in the process of painting the facility to address the marred kitchen walls and the walls in bedrooms # 2 and 7, the 3rd floor communal restroom, and the 3rd floor lounge. Additionally, the painter will address chalking issues. Regularly scheduled maintenance inspections will be conducted by the maintenance department under the supervision of the Director of Operations and Director of Maintenance to ensure the corrective action is implemented and the deficiency does not recur. The facility will be in full compliance by October 30, 2011. |
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 a review of client records and a review of the projects policy and procedures manual, the facility failed to document a physical examination in two of four client records.
The findings include:
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.
Four client records were reviewed for documentation of a physical examination on May 16, 2011.
The facility did not document a physical examination within the first week of admission, as per facility policy, in client records # 1, and 3.
Client # 1 was admitted to the program on 2/24/11, the facility failed to document a physical examination at the time of review on 5/16/11.
Client # 3 was admitted to the program on 3/1/11, the facility failed to document a physical examination at the time of review on 5/16/11.
This is a repeat citation.
This area of noncompliance was also identified during the licensing inspections conducted on 10/8/04 and 8/15/07 (plan of correction approved on 8/27/10.)
The facility was previously cited on 6/4/08 for failing to document a physical examination.
In response to the citation issued on 6/4/08, the facility's plan of correction submitted on 6/12/08 and approved on 6/20/08 stated the following:
Plan of Correction will be as follows: "All Clients will have updated psych-socials and physicals upon interview and will not be admitted until all requested documentation is received by Clinical Staff. Counselor III will monitor compliance for physical examinations documents and report findings for three months in CQI. Program Director will oversee this Plan of Correction"
The facility was previously cited on 12/2/10 for failing to document a physical examination.
In response to the citation issued on 12/2/10, the facility's plan of correction submitted on 12/12/10 and approved on 1/26/11 stated the following:
"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."
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Plan of Correction
Client #1 and #3 have discharged from the program. An in-service training is scheduled for 6/10/11 to instruct Staff on Physical Examination policy and protocol. In the event a client is admitted without a verifiable physical examination, the chart will be flagged and immediately delivered to the Program Director to ensure that this client is a priority for referral to a medical facility within one week for a physical examination. To ensure this deficiency does not recur supervision staff will monitor compliance for physical examination documents weekly and progressive corrective actions will be instituted by the Program Director to ensure compliance. The facility will be in full compliance by August 31, 2011. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, a review of the facility's policies and procedures manual, and a conversation with the facility director, the facility failed to document a psychosocial evaluation in accordance with facility policy in three of four client records.
The facility's policy titled "Biopsychosocial" states:
The biopsychosocial assessments and diagnostic summary must be complete and comprehensive in its entirety. All presenting problems are to be listed. Client strength and weaknesses are to be included. It must be obvious to the reader that the assessment and diagnostic summary was based on information that was recorded in the biopsychosocial. Initial clinical goals and objectives that are listed in the assessment component must be addressed and further developed in the clinical problem list. The clinical problem list and the summary assessment are the bridge to the client's initial treatment plan.
The biopsychosocial, with accompanying assessment and diagnostic summary must be completed within 3-5 days of the client's admission. The QI Committee reviews every fourth client per counselor to ensure that the biopsychosocial is comprehensive, that the initial assessments and diagnostic summary are formulated upon information that is contained in the biopsychosocial and that the proposed initial individualized treatment plan is relevant to the content of the data assessed.
The findings include:
Four client records were reviewed for documentation of a psychosocial evaluation on May 16, 2011.
The facility did not document a psychosocial evaluation in accordance with facility policy in client records # 1, 2, and 3.
Client # 1 was admitted to the program on 2/24/11.
A psychosocial was documented on 3/3/11; however, it failed to address coping mechanisms, attitude and receptivity towards treatment, and clinical impressions (DSM IV axis) per policy.
Client # 2 was admitted to the program on 4/7/11.
The facility failed to document a psychosocial evaluation for client # 2 at the time of review on 5/16/11.
Client # 3 was admitted to the program on 3/1/11.
The facility failed to document a psychosocial evaluation for client # 3 at the time of review on 5/16/11.
The facility director stated that there may be areas of noncompliance due to a transition, one counselor recently terminated the program and another counselor was newly hired.
This is a repeat citation.
This area of noncompliance was also identified during the licensing inspection conducted on 9/25/06 (plan of correction approved on 9/29/06.)
This area of noncompliance was also identified during the licensing inspection conducted on 8/15/07 (plan of correction approved on 8/27/07.)
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Plan of Correction
Client #1 and #3 have discharged from the program. The necessary corrections have been made in Client #2's chart. On Friday, June 10, 2011 the Program Director will address documentation of psychosocial evaluations in accordance with facility policy. Psychosocial evaluation coping mechanisms, attitude and receptivity towards treatment will be addressed to ensure clinicians are able to address client strengths, needs, ability, preference, and resilience. CQI committee will address revising the Psychosocial Evaluation Form format. To ensure this deficiency does not recur, charts will be monitored by supervision staff and progressive corrective actions will be instituted by the Program Director to ensure compliance. The facility will be in full compliance by August 31, 2011. |
709.52(a) LICENSURE Individual TX and REHAB Plan
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:
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Observations
Based on a review of client records and a review of the facility's policies and procedures manual, the facility failed to document an individual treatment plan in accordance with facility policy in three of three client records.
The facility's policy titled "Treatment & Rehabilitation Services" states:
The individual treatment plans are developed utilizing Psychosocial Histories and Evaluations, Medical History, the Strength, Needs, Ability and Preferences self report, and the Intake Counselor ' s impressions. Subsequent treatment plans are developed by the Client and Primary Counselor, and are geared toward individual need, as reflected by the client problem list, treatment plan updates, case consultations and progress notes. The Chesapeake region utilizes the following Maryland COMAR Regulation procedures for treatment plan updates: Intermediate Care Facilities (weekly review and updates): Long term/Therapeutic Communities (30 day updates): Intensive Out-patient (30 day updates); Outpatient (90 day updates); Halfway Houses (60 day updates).
On May 16, 2011 three client records were reviewed for documentation of an individual treatment and rehabilitation plan.
The facility failed to document an individual treatment and rehabilitation plan in accordance with facility policy in client records # 1, 2, and 3.
Client # 1 was admitted to the program on 2/24/11.
An individual treatment and rehabilitation plan was documented on 3/31/11.
However, the psychosocial evaluation that was documented on 3/3/11 failed to address coping mechanisms, attitude and receptivity towards treatment, and clinical impressions, thus the facility failed to document an individual treatment and rehabilitation plan utilizing Psychosocial Histories and Evaluations, Medical History, the Strength, Needs, Ability and Preferences self report, and the Intake Counselor ' s impressions as outlined per policy.
Client # 2 was admitted to the program on 4/7/11.
An individual treatment and rehabilitation plan was documented on 4/11/11.
However, the facility failed to document a psychosocial evaluation for client # 2 at the time of review on 5/16/11, thus the facility failed to document an individual treatment and rehabilitation plan utilizing Psychosocial Histories and Evaluations, Medical History, the Strength, Needs, Ability and Preferences self report, and the Intake Counselor ' s impressions as outlined per policy.
Client # 3 was admitted to the program on 3/1/11.
An individual treatment and rehabilitation plan was documented on 3/4/11.
However, the facility failed to document a psychosocial evaluation for client # 3 at the time of review on 5/16/11, thus the facility failed to document an individual treatment and rehabilitation plan utilizing Psychosocial Histories and Evaluations, Medical History, the Strength, Needs, Ability and Preferences self report, and the Intake Counselor ' s impressions as outlined per policy.
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Plan of Correction
An in-service facilitated by the Program Director will occur on 6/17/11 to address Treatment and rehabilitation service Individual TX plan. Ongoing training will be provided by the Gaudenzia Training Institute. Program Director will monitor charts closely to ensure compliance. Corrective actions will be instituted for non-compliance. Additionally, charts will be monitored through our Continues Quality Improvement Program. The facility will be in full compliance by August 31, 2011. The Program Director will ensure compliance. |
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 a review of client records, a review of the projects policy and procedures manual, and a conversation with the facility director, the facility failed to document a treatment plan update per policy in three of four client records.
The findings include:
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.
Four client records were reviewed for documentation of a treatment and rehabilitation update on May 16, 2011.
The facility did not document a treatment plan update, as per facility policy, in client records # 1, 2, and 3.
Client # 1 was admitted to the program on 2/24/11.
The comprehensive treatment plan was documented on 3/31/11.
The facility documented a late treatment and rehabilitation update on 5/5/11, the treatment and rehabilitation update should have been complete by 5/1/11.
Client # 2 was admitted to the program on 4/7/11.
The comprehensive treatment plan was documented on 4/11/11.
The facility failed to document a treatment and rehabilitation update at the time of review on 5/16/11.
Client # 3 was admitted to the program on 3/1/11.
The comprehensive treatment plan was documented on 3/4/11.
The facility failed to document a treatment and rehabilitation update at the time of review on 5/16/11.
The facility director stated that there may be areas of noncompliance due to a transition, one counselor recently terminated the program and another counselor was newly hired.
This is a repeat citation.
The facility was previously cited on 6/10/10 for failing to document a treatment and rehabilitation update at least every 30 days.
In response to the citation issued on 6/10/10, the facility's plan of correction submitted on 6/26/10 and approved on 7/27/10 stated the following:
"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)"
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Plan of Correction
An in-service facilitated by the Program Director will occur on 6/17/11 to address Treatment and rehabilitation service TX plan Update. Ongoing training will be provided by the Gaudenzia Training Institute. Program Director will monitor charts closely to ensure compliance. Corrective actions will be instituted for non-compliance. Additionally, charts will be monitored through our Continues Quality Improvement Program. The facility will be in full compliance by August 31, 2011. The Program Director will ensure compliance. |
709.52(d) LICENSURE Regularity of counseling provided
709.52. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
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Observations
Based on a review of client records and an interview with the facility director, the facility failed to ensure that counseling was provided to a client on a regular and scheduled basis.
The findings include:
Four client records were reviewed on May 16, 2011 to ensure that regular and scheduled counseling was provided.
The facility did not document regular and scheduled counseling for client # 2 and 3.
Client # 2 was admitted to the program on 4/7/11, and currently remains in the program.
The individual treatment plan that was documented on 4/11/11 prescribed individual sessions once a week and group sessions twice a week.
The facility documented two counseling sessions for client # 2 on 4/25/11 (group session) and 4/26/11 (individual session).
The facility failed to document counseling sessions for the month of May 2011 as prescribed in the individual treatment plan.
Client # 3 was admitted to the program on 3/1/11, and currently remains in the program.
The individual treatment plan that was documented on 3/4/11 prescribed individual sessions once a week and group sessions twice a week.
The facility documented individual sessions on 4/10/11, 4/10/11, 3/28/11, 3/11/11, and 3/4/11. Group sessions were documented on 4/29/11, 4/4/11, 3/28/11, 3/21/11, and 3/18/11.
The facility failed to document counseling sessions for the month of May 2011 as prescribed in the individual treatment plan.
The facility director confirmed that the facility is going through a transition as one counselor recently terminated the program and another counselor was newly hired.
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Plan of Correction
An in-service facilitated by the Program Director will occur on 6/17/11 to address regularity of counseling provided. Ongoing training will be provided by the Gaudenzia Training Institute. Counseling notes will be reviewed by Program Director weekly. Corrective actions will be instituted for non-compliance. The facility will be in full compliance by August 31, 2011. The Program Director will ensure compliance. |
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of client records, the standards for inpatient non-hospital activities, and an interview with the facility director, the facility failed to verify that any work done by the client is an integral part of the treatment and rehabilitation plan in four of four client records reviewed.
The findings include:
Four client records were reviewed for documentation of work therapy on May 16, 2011.
The facility did not document work therapy in the comprehensive or treatment plan updates in client records # 1, 2, 3, and 4.
Standard 709.53(a)(12) states:
Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
An interview with the facility director confirmed that client's participate in work outside of cleaning their personal space and that documentation has not been done.
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Plan of Correction
An in-service facilitated by the Program Director will occur on 6/17/11 to address Work as treatment. This in-service will demonstrate identifying and documenting life skills, coping skills, and socialization in recovery through Work Therapy. Documentation of work therapy will be reviewed by Program Director weekly.
The facility will be in full compliance by August 31, 2011. The Program Director will ensure compliance.
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709.54(c) LICENSURE Follow-up policy
709.54. Project management services.
(c) The project shall develop a written client follow-up policy.
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Observations
Based on a review of the facility's policy and procedure manual, the facility failed to develop a written client follow-up policy that accurately reflects their follow-up process.
The findings include:
From May 9, 2011 through May 11, 2011, the facility's policy and procedure manual was reviewed. The facility had two conflicting procedures regarding attempts to follow up on clients.
The facility's policy titled: "Follow Up Information," states:
" All clients are followed up after discharge.
Follow up information shall be conducted for each client after discharge from the program, unless there is specific client refusal for follow up. Each program will maintain a follow up policy outlining the specific steps taken. The follow up log binder will house the documentation of each follow up attempt.
Primary Counselors and/or any designee of the Program/Clinical Supervisor or Director shall assume responsibility for client follow up.
In the case where a client has been referred to a specific outside resource for continued care post discharge from the project, follow up should be completed via a telephone call with the resource within one week of the client's initial referral appointment to the resource. Once the attempt has been made and documented in the follow up log binder, a program may consider its obligation to the individual fulfilled. This procedure will follow for client ' s who are nor referred after discharge. The worker will attempt to contact the client directly via telephone and document the findings in the log binder.
In instances where the client refuses follow up, the refusal shall be documented on the Follow Up form and in a progress note [remember to state the reason for the refusal in the note and on the form].
Where clients are not referred after discharge, the clinical supervisor or their designee will call the client in 30 days. Contact will be logged in the Follow Up Log binder.
.Follow up information shall include the client's status with the referral resource/resource disposition, sobriety status, 12 step/support group involvement, and overall progress with aftercare goals. "
The facility ' s policy and procedure manual contained a second written policy titled: " FOLLOW UP INFORMATION. " This second policy states: "Regardless of the type of discharge, attempts are made to followed up all clients post discharge. When a client has been discharged and referred to an outside source, the program will, with the written consent of the client and within one week from the day the referral is to be completed, attempt to determine from the resource the disposition of the referral. Once the attempt has been made and documented in the follow up log book, the program may consider its obligation to the individual fulfilled. The administrative assistant or designee by the program supervisor. When the client refuses a referral after discharge (this includes ASA, Therapeutic Discharge or completions who refuse the next level of care on the continuum), an attempt will be made by the administrative assistant or supervisor's designee, to follow-up the discharged client's progress and well being and to maintain an opportunity for either re-admission to the program or admission to the next level of care on the continuum should circumstances warrant it as necessary and appropriate. This will occur within the 7 days post discharge. Information shall be kept in the follow up log binder."
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Plan of Correction
The Program Director has consulted with organization management to provide clarification to resolve conflicting policies. An in-service training to address the practiced follow-up procedure will take place on 6/10/11 to instruct Staff on how to document follow-up within seven days for referrals and thirty days for non referrals. The facility will be in full compliance by August 31, 2011. The CQI Committee will ensure continued compliance. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of areas of noncompliance identified during this licensing inspection that had previously been cited, the facility failed to comply with prior plans of correction approved by the Department.
The findings include:
On May 16, 2011 the facility was again found to be out of compliance with the following standards:
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.
This area of noncompliance was also identified during the licensing inspection conducted on 6/10/10 (plan of correction submitted on 6/26/10 and approved on 7/27/2010).
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
This area of noncompliance was also identified during the licensing inspection conducted on 9/25/06 (plan of correction approved on 9/29/06), and 8/15/07 (plan of correction approved on 8/27/10).
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
This area of noncompliance was also identified during the licensing inspection conducted on 10/8/04, 8/15/07 (plan of correction approved on 8/27/10), 6/04/08 (plan of correction submitted on 6/12/08 and approved on 6/20/08), and 12/2/10 (plan of correction submitted on 12/12/10 and approved on 1/26/11).
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Plan of Correction
709.51.B5 Client #1 and #3 have discharged from the program. An in-service training is scheduled for 6/10/11 to instruct Staff on Physical Examination policy and protocol. In the event a client is admitted without a verifiable physical examination, the chart will be flagged and immediately delivered to the Program Director to ensure that this client is a priority for referral to a medical facility within one week for a physical examination. To ensure this deficiency does not recur supervision staff will monitor compliance for physical examination documents weekly and progressive corrective actions will be instituted by the Program Director to ensure compliance. The facility will be in full compliance by August 31, 2011. The facility director will ensure that the facility complies with all future plans of correction approved by the Department by the completion date that was accepted. In order to monitor compliance so that the deficiency does not recur, the facility director will meet with the appropriate department head one month prior to the due date of completion and weekly thereafter to ascertain that status. If it is determined that the facility will not meet that date of completion a letter requesting an extension will be sent o the Department.
709.51.B Client #1 and #3 have discharged from the program. The necessary corrections have been made in Client #2's chart. On Friday, June 10, 2011 the Program Director will address documentation of psychosocial evaluations in accordance with facility policy. Psychosocial evaluation coping mechanisms, attitude and receptivity towards treatment will be addressed to ensure clinicians are able to address client strengths, needs, ability, preference, and resilience. CQI committee will address revising the Psychosocial Evaluation Form format. To ensure this deficiency does not recur, charts will be monitored by supervision staff and progressive corrective actions will be instituted by the Program Director to ensure compliance. The facility will be in full compliance by August 31, 2011. The facility director will ensure that the facility complies with all future plans of correction approved by the Department by the completion date that was accepted. In order to monitor compliance so that the deficiency does not recur, the facility director will meet with the appropriate department head one month prior to the due date of completion and weekly thereafter to ascertain that status. If it is determined that the facility will not meet that date of completion a letter requesting an extension will be sent o the Department.
709.52.B An in-service facilitated by the Program Director will occur on 6/17/11 to address Treatment and rehabilitation service Individual TX plan. Ongoing training will be provided by the Gaudenzia Training Institute. Program Director will monitor charts closely to ensure compliance. Corrective actions will be instituted for non-compliance. Additionally, charts will be monitored through our Continues Quality Improvement Program. The facility will be in full compliance by August 31, 2011. The Program Director will ensure compliance. The facility director will ensure that the facility complies with all future plans of correction approved by the Department by the completion date that was accepted. In order to monitor compliance so that the deficiency does not recur, the facility director will meet with the appropriate department head one month prior to the due date of completion and weekly thereafter to ascertain that status. If it is determined that the facility will not meet that date of completion a letter requesting an extension will be sent o the Department.
The facility has hired new counselors who are in orientation training. Their orientation training plan is designed to assist them in achieving compliance with all DOH clinical documentation criteria. We are conducting in-service trainings and supervision on an on-going basis. The Program Director has been designated as the point person responsible for compliance. The program will be monitored by the Drug and Alcohol Division Director on a monthly basis. The facility will be in full compliance by August 31, 2011. To ensure deficiencies do not reoccur progressive corrective actions will be instituted by the Program Director. The Program Director will ensure compliance.
Contributing to these deficiencies was staff turnover and prolonged staff vacancies.
Currently the facility is fully staffed and we are developing resources to ensure that we will have a pool of applicants for any future vacancies.
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