INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on June 1-4, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Erie Inc. Corry Satellite Office 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 July 3, 2009.
|
Plan of Correction
|
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
|
Observations
Based on a calculation of the counselor caseloads, the facility failed to provide caseloads that do not exceed 35 active clients.
The findings include:
Counselor caseloads were calculated on June 4, 2009. Counselor #3 has a caseload of 40:1 which exceeds the maximum of 35 active clients.
|
Plan of Correction
A full-time outpatient counselor position was added to the roster and interviews are currently being conducted for that position |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
|
Observations
Based on a review of the fire drill record, the facility failed to conduct and document fire drills at least once a month.
The findings include:
Based on a review of the fire drill record on June 3, 2009, the facility failed to conduct and document a fire drill for April 2009.
|
Plan of Correction
7All staff have been trained on the fire drill expectations and regulations. Gaudenzia Erie Inc.'s maintenance worker will follow up with the satellite offices monthly to insure fire drill completions. The Program Supervisor will also monitor the adherence of the drills. (complete date: immediately)
|
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
|
Observations
Based on a review of the client records, the facility failed to document a complete medical history in six of eight client records.
The findings include:
Eight client records were reviewed on June 2, 2009. A complete medical history which includes a personal history, family history, and a history of symptoms and illnesses, was required in eight client records. The facility failed to document a complete medical history in client records # 1, 3, 4, 5, 7 and 8.
|
Plan of Correction
A medical history addendum form has been added to all file medication sections to be completed upon intake. The Program Supervisor will train staff and monitor the correct use of this form.
|
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
|
Observations
Based on a review of the client records, the facility failed to document a treatment plan update in one of four client records, and failed to include an assessment of the clients' progress on the goals of the treatment plan in one of four client records.
The findings include:
Eight client records were reviewed on June 2, 2009. A treatment plan update which includes an assessment of the clients progress on the goals of the treatment plan was required in four client records. Client record #1 had a treatment plan update which was due on 5-4-09, but it was not documented as of June 4, 2009. Client record #6 documented a treatment plan update but it did not include an assessment of the clients progress on the goals of the treatment plan.
|
Plan of Correction
The Program Supervisor will utilize the weekly staff meetings to re-train clinical staff on the correct procedure for treatment plans. This will be reviewed by the supervisor through the monthly PI process.
|
709.93(a)(2) LICENSURE Client records
709.93. 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.
|
Observations
Based on a review of the client records, the facility failed to document a complete medication record in three of seven client records.
The findings include:
Eight client records were reviewed on June 2, 2009. A complete medication record which includes the medication name, dose and frequency of use was required in seven client records. Client records # 1, 2, and 3 included medication records which only listed the medication name.
|
Plan of Correction
A medical history addendum form has been added to all file medication sections to be completed upon intake. The Program Supervisor will train staff and monitor the correct use of this form.
|