INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 20, and 21, 2018 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia, Inc. Broad Street was found to be not 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(a)(2) LICENSURE Tx type & frequency
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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
The facility failed to document type and frequency of treatment and rehabilitation services on treatment plans in three out of seven client records.
Client #2 was admitted on April 17, 2018 and still an active client as of the date of this inspection. A comprehensive treatment plan dated 5/15/18 and a treatment plan update dated 6/15/18 did not include type and frequency of treatment and rehabilitation services.
Client #3 was admitted on May 9, 2018 and still an active client as of the date of this inspection. A comprehensive treatment plan dated 5/25/18 did not include type and frequency of treatment and rehabilitation services.
Client #4 was admitted on April 13, 2018 and still an active client as of the date of this inspection. A treatment plan update dated 6/18/18 did not include type and frequency of treatment and rehabilitation services.
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Plan of Correction
The electronic treatment plan form is currently undergoing revision to provide space to specify both type and frequency of interventions as well as prompts to remind the clinician to address this area. These revisions will be completed and fully implemented by 7/31/18. Program management will ensure that treatment plans are properly utilized through ongoing regular chart audits." The Program Director/Program Supervisor(s) will conduct an in-service training on tx plan documentation practices by 8/2/18 in addition to providing feedback to the counselors during supervisory sessions |