INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 17, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Erie Inc. Community 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 January 17, 2008.
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Plan of Correction
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709.51(b)(3)(iii) LICENSURE Personal History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records the facility failed to document a complete personal history in two out of two client records reviewed, specifically client records # 5 and 6. Personal histories did not include pertinent personal data on legal, employment, educational, recreational and sexual histories.
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Plan of Correction
Program Director will train staff on personal histories and the need to have all areas addressed fully which include legal, employment, educational, recreational and sexual histories. She will monitor compliance monthly during the agency's Quality Improvement process. |
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 review of client records, the facility failed to document complete progress notes in two out of two client records reviewed, specifically client records # 5 and 6. The group progress notes did not include a data section that was individualized per group by the counselor that included observation and information about the client; and the assessment did not include the counselor's analysis of and conclusions regarding the client's interactions during the group sessions. The inspector was unable to determine if the group notes were clinical/therapeutic or educational.
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Plan of Correction
Division Director will train all clinical staff on the appropriate way to complete clinical group notes. This clinical staff training will be held on or before 2/29/08. Program Directors and Supervisors will monitor compliance during the agency's monthly Quality Improvement program. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on review of client records the facility failed to document a complete personal history in three out of three client records reviewed, # 1, 2, and 3. Personal histories did not include pertinent personal data on family, employment, educational, recreational, and sexual histories. Personal history forms would ask for more detailed information than was documented on the histories.
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Plan of Correction
Program Director will be train staff on personal histories and the need to have all areas addressed fully which include data on family, employment, educational, recreational, and sexual histories. She will monitor compliance during monthly Quality Improvement process. |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on review of client records, the facility failed to document complete progress notes in two out of three records reviewed, # 1 and 2. The group progress notes did not include a data section that was individualized per group by the counselor that included observation and information about the client; and the assessment did not include the counselor's analysis of and conclusions regarding the client's interactions during the group sessions. The content of the notes made it difficult to determine whether the group notes were clinical/therapeutic or educational.
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Plan of Correction
Division Director will train all clinical staff on the appropriate way to complete clinical group notes. This clinical staff training will be held on or before 2/29/08. Program Directors and Supervisors will monitor compliance during the agency's monthly Quality Improvement program. |