INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 27-28, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Gatehouse for Men 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 March 12, 2009.
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Plan of Correction
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709.28(d) LICENSURE Confidentiality
709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
Based on a review of client records, the facility failed to document if a copy of the consent for the release of information form was offered to the client in six of six client records.
Findings:
Six client records were reviewed on December 28, 2008. Documentation of whether the client was offered a copy of the consent to release information form was required in six client records. The facility did not document if the client was offered a copy of the release of information form to the emergency contact in client records # 1, 2, 3, 5 and 6.
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Plan of Correction
The Clinical Supervisor has revised the Consent to Release Information form to reflect documentation that the client was offered a copy of the Release of Information form to the Emergency Contact. The Clinical Supervisor has and will continue to train all clinical employees. The Clinical Supervisor will also assure continued compliance by monitoring charts on a weekly basis. |
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, the facility failed to document treatment plan updates in three of three client records.
Findings:
Six client records were reviewed on January 28, 2009. Treatment plan updates were required in three client records. The facility failed to document treatment plan updates to include an assessment of the client ' s progress in relationship to the stated goals of the comprehensive treatment plan in client records # 1, 2 and 3.
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Plan of Correction
The Clinical Supervisor will revise the treatment plan to include a specific format to include treatment plan updates. The Clinical Supervisor will train all clinical staff on the implementation of treatment plan updates. Compliance will be assured by weekly chart review by the Clinical Supervisor. Full compliance will be achieved by March 30, 2009. |
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 a review of client medication administration records, the facility failed to document missed medication dosages.
Findings:
Three client medication records were reviewed on January 28, 2009. Medication records were required to indicate the reasons for missed medication. The facility failed to document the reasons for missed medication in client records # 1 and 3.
Client record #1 prescribed Allopurinal 300mg, 1 tablet in the A.M.
The facility did not document the reason why this medication was missed on dates:
10/26/08, 10/27/08, 10/28/09, 11/30/08
The facility indicated "Other " as the reason why this medication was missed on dates:
12/02/08, 12/04/08, 12/05/08, 12/06/08, 12/07/08 12/09/08 and 12/10/08
Client record #3 prescribed Allopurinal 100mg, 1 tablet daily.
The facility did not document the reason why this medication was missed on dates:
12/24/08 and 12/30/08
The facility indicated "Other " as the reason why this medication was missed on dates:
12/02/08, 12/10/08, 12/20/08, 12/25/08, 12/26/08 and 12/28/08
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Plan of Correction
The Clinical Supervisor has removed "other" as the reason why medication was missed. The Medication Log form has been changed to reflect specific reasons why medication has been missed. The Clinical Supervisor will provide training to all staff members responsible for monitoring clients taking medication for proper documentation. Clinical Supervisor will assure compliance by reviewing Medication Logs on a weekly basis. Fulll compliance will be achieved by 3/15/09. |
709.53(a)(5) LICENSURE Progress Notes
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:
(5) Progress notes.
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Observations
Based on a review of client records the facility failed to document progress notes in three of three client records.
Findings:
Six client records were reviewed on January 28, 2009. Progress notes were required in three client records. The facility failed to document group progress notes to include a comment relative to the client ' s response or participation in client records # 1, 2 and 3.
Group progress notes did not include a comment relative to each client ' s response or participation in client records 1, 2 and 3 on dates:
11/26/08, 11/28/08, 12/04/08 and 12/18/08
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Plan of Correction
The Clinical Supervisor will train all clinical employees to include a comment relative to the client's response or participation. Full compliance was achieved 2/10/09. The Clinical Supervisor will asssure compliance by monitoring charts on a weekly basis. |