INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 3, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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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 the type and/or frequency of services on the individual treatment and rehabilitation plans in five of seven client records.
The findings include:
Seven client records were reviewed on December 3, 2015. The type and frequency of services were required in the individual treatment and rehabilitation plan in client records, #2, 3, 5, 6 and 7.
Client #2 was admitted on November 4, 2015. The individual treatment and rehabilitation plan was completed on November 25, 2015. The facility failed to document the type and frequency of services on client #2's individual treatment and rehabilitation plan.
Client #3 was admitted on November 11, 2015. The individual treatment and rehabilitation plan was completed on November 25, 2015. The facility failed to document the type and frequency of services on client #3's individual treatment and rehabilitation plan.
Client #5 was admitted on October 13, 2015. The individual treatment and rehabilitation plan was completed on October 27, 2015. The facility failed to document the frequency of services on client #5's individual treatment and rehabilitation plan.
Client #6 was admitted on October13, 2015. The individual treatment and rehabilitation plan was completed on October 27, 2015. The facility failed to document the type and frequency of services on client #6's individual treatment and rehabilitation plan.
Client #7 was admitted on October 13, 2015. The individual treatment and rehabilitation plan was completed on October 16, 2015. The facility failed to document the frequency of services on client #7's individual treatment and rehabilitation plan.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will assure that
the facility documents the type and frequency of services on the individual treatment and rehabilitation plans in each client's record.
Each Counselor was reminded in supervision to complete the service frequency and type check-boxes located on all treatment plan forms. Treatment plan check-boxes were completed on current records.
The Program Director will monitor ongoing conformance by conducting monthly chart audits and reporting in the Continuous Quality Improvement system.
Targeted Correction Date: 12/17/15 |
709.53(a)(3) LICENSURE Records of Service
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:
(3) Record of services provided.
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Observations
Based on the review of client records, the facility failed to provide records of service in the client records.
The finding included:
Seven client records were reviewed on December 3, 2015. Each was required to have a record of service which includes information relative to the client's involvement with the project. The facility failed to document records of services in two client records, #5 and 7.
Client #5 was admitted 10/13/15 and the last counseling session documented on a progress note was 11/25/15, all other individual sessions and group counseling was missing from the service record. As of the date of the licensing inspection there was no documentation of client #5 services that were provided on a service record.
Client #7 was admitted 10/16/15 and the last counseling session that was documented was on 10/16/15 on the record of service, all other individual sessions and group counseling was missing from the service record. . Client #7 last treatment plan was signed and dated 10/28/2015. As of the date of the licensing inspection there was not service documentation of client #7 in a record of service.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As per prior submission on 12/17/15,
The Program Director will assure that the facility provides a completed record of service in all client records.
A blank Record of Service document was provided to each Counselor and the importance of completing such per regulation was reviewed in supervision. A record of Service form was completed and placed in each current record.
The Program Director will monitor ongoing conformance via monthly chart audits and report in the Continuous Quality Improvement meeting.
New Target Date of Completion: 4/1/16 |