INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on November 11, 2016 through November 9, 2016 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Gaudenzia DRC, Inc., 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:
|
Plan of Correction
|
709.28 (c) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
|
Observations
Based on a review of client records, the facility failed to identify the specific information to be disclosed in 7 of 12 records reviewed.
Client records # 1, 2, 4, 5, 8, 9 &11 contained consent to release information forms to family where the area for information to be released had "other" checked, but, lacked documentation as to what other information was to be released.
Client record #1 consent form dated 9/7/16.
Client record #2 consent form dated 9/27/16.
Client record #4 consent form dated 8/10/16.
Client record #5 consent form dated 9/15/16.
Client record #8 consent form dated 9/2/16.
Client record #9 consent form dated 8/13/16.
Client record #11 consent form dated 9/15/16.
|
Plan of Correction
All consent to release information forms will be reviewed in advance by the clinical supervisor and or the inpatient director to ensure proper information is being released to any family member. The area of "other" will specify what other information will be released and will not be left blank.
The facility will conduct a training for all clinical staff on proper procedure for completing consent to release forms by January 30, 2017. Each staff member will be trained and sign off on the training. As new counseling staff are hired, this will be part of their initial 120 day clinical training. All trainings will de documented and become part of their training files. Clinical Supervisor and or Inpatient Director will monitor and review all consent to release forms for a period of ninety days. They will also conduct random review of clients charts to ensure that all consent to release forms are being completed correctly.
Clients #1, #2, #4, #5, #8, #9 & 11 have all been discharge from the program.
|
709.28 (c) (3) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
|
Observations
Based on a review of client records, the facility failed to identify the purpose for the release of information to be disclosed in 7 of 12 records reviewed.
Client records # 1, 2, 4, 5, 8, 9 &11 contained consent to release information forms to family where the purpose for the release of information was not documented. The consent to release information forms had multiple checkboxes to select from based upon the purpose for the release. Rather than selecting those that would be applicable for releases of information to family members, all checkboxes were selected, some of which would not pertain to the release of information to family.
Client record #1 consent form dated 9/7/16.
Client record #2 consent form dated 9/27/16.
Client record #4 consent form dated 8/10/16.
Client record #5 consent form dated 9/15/16.
Client record #8 consent form dated 9/2/16.
Client record #9 consent form dated 8/13/16.
Client record #11 consent form dated 9/15/16.
|
Plan of Correction
The consent to release information forms will be reviewed by admission supervisor to address specific information being release to any family member and or outside agency. These review will be conducted for a period of ninety days and followed up randomly by the clinical supervisor and or inpatient director, All consent to release forms will have selected area that are applicable for releasing information.
The facility will conduct a training on how to properly complete a consent to release information form and ensuring that all required information is included on the consent form. This training will be held on January 30, 2017.
Clients #1,#2,#4,#5,#8,#9 & 11 have all been discharged from the program. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
|
Observations
Based on a review of client records, the facility failed to document a complete physical examination in 3 of 12 records reviewed.
Client record #2 contained a physical examination dated 9/28/16; however, the physical examination did not include the client's vital signs.
Client record #4 contained a physical examination dated 10/26/16; however, the physical examination did not include the client's vital signs.
Client record #11, lacked documentation that a physical exam had been completed.
This was discussed with facility staff at the time of the inspection.
|
Plan of Correction
All physical examinations documentation will be reviewed by medical department personnel to ensure that all client's vital signs are noted on each physical form.
The clinical supervisor and or inpatient director will ensure that all clients receive a physical exam within the first seven days and the exam is documented properly.
To ensure that all exams have all vital signs completed, the clinical supervisor and or inpatient director will review the examination documents forms for completion.
Clients #2, #4, & #11 have all been discharged from the program. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of client records, the facility failed to document psychosocial evaluations that were evaluative in 11 of 12 records reviewed.
Psychosocial evaluations in client records 1 through 6 and records 8 through 12, were simply a repeat of what the client said ora repeat of the histories.
This was discussed with facility staff at the time of the inspection.
|
Plan of Correction
All psychosocial evaluations will be reviewed and discussed with the clinical supervisor and or inpatient director to address each individual client's history. Each psychosocial evaluation will be required to include detailed information about the client and their history. A training will be provided to all clinical staff on how to properly complete a psychosocial evaluation by January 31, 2017. This training will be documented and become part of the training file.
The clinical supervisor and or inpatient director will conduct random reviews of all evaluations to ensure that all that these deficiencies do not occur again for a ninety day period of time and randomly thereafter for compliance.
Clients 1 - 6 and 8 - 12 have all been discharged from the program. |
709.52(a)(3) LICENSURE Support service type
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:
(3) Proposed type of support service.
|
Observations
Based on a review of client records the facility failed to include support services on the treatment plans in 8 of 12 records reviewed and failed to document the type and frequency of services to be provided in 1 of 12 reviewed.
Treatment plans in client records #s 1 through 5 and #s 9 through 11 lacked documentation of support services. Additionally, the treatment Folan in client record #11 lacked the type and frequency of services to be provided.
This was discussed with facility staff at the time of the inspection.
|
Plan of Correction
The clinical supervisor and or inpatient director will review each individual treatment plan to ensure that all plans include the proposed type of support service for each individual, they will also include the frequency of each service provided. |
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.
|
Observations
Based on a review of client records the facility failed to document treatment plan updates and/or failed to document treatment plan updates that reflected a progress on goals in 5 of 9 records where it was applicable.
Treatment plan updates in client records #s 1, 2, 3 & 4 lacked documentation of progress on treatment plan goals form the comprehensive treatment plan. client records #4 & 6 were missing some of the required treatment plan updates and had some that were documented late.
This was discussed with facility staff at the time of the inspection.
|
Plan of Correction
Clinical supervisor and or inpatient director will review each treatment plan update to ensure that all plans reflect the progressive goals where applicable. In addition all clinical staff will be required to document the goal change in an individual case note. |