INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 17, 2008 and June 18, 2008 Gaudenzia Together House by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Together House 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 16, 2008.
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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
Individualized treatment and rehabilitation plans failed to include written documentation of the type and frequency of treatment and rehabilitation services.
Findings:
Seven of eight client records reviewed on June 18, 2008 failed to include the type and frequency of treatment and rehabilitation services on the individualized treatment and rehabilitation plans.
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Plan of Correction
Program Supervisors conducted staff in-service training emphasizing the need to include type and frequency of treatment and rehabilitation services on the treatment and rehabilitation services plan. Program Supervisors and/or the Program Director will be responsible for providing oversight monitoring of compliance through clinical supervision and review of each treatment and rehabilitation plan. |
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Client records failed to document work therapy as an integral component of the treatment and rehabilitation plan.
Findings:
Seven of eight client records reviewed on June 18, 2008 failed to document work therapy verification in the individualized treatment and rehabilitation plans.
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Plan of Correction
Program Supervisors Conducted a staff in-service training emphasizing the need to include work therapy as an integral component of the treatment and rehabilitation plan. Program Supervisors and the Program Director will be responsible for providing oversight monitoring for compliance as part of the provision of clinical supervision and continuous quality improvement. |