INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 21, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Erie, Inc - Daniel Snow 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.
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Plan of Correction
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709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records and an interview with the house manager, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, in one of one client record.
The findings include:
Six client records were reviewed on October 21, 2013. One record was required to contain documentation that the the client was notified in writing, of a decision to involuntarily terminate the client's treatment at the project. The facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, in client record #5.
Client #5 was admitted into treatment on August 28, 2013 and was involuntarily terminated from the project on October 6, 2013. There was no documentation of written notification to the client, at the time of the licensing inspection. The house manager explained that the form was given to the client, but there was no documentation that the patient was given written notification.
The findings were reviewed with the house manager and were not disputed.
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Plan of Correction
1)Program Supervisor completed a training on the administrative discharge form on 11/08/13 with all clinical staff.
2)Program Supervisor will audit all administrative discharges over the next 6 months and ensure that administrative discharge paperwork was completed properly and a copy was placed in the file.
3) Program Supervisor will review his findings monthly during program meetings with Division Director. |
709.33(b) LICENSURE Notification of Termination
709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records and an interview with the house manager, the facility failed to notify the client of an opportunity to request reconsideration of a decision terminating treatment in one of one client record.
The findings include:
Six client records were reviewed on October 21, 2013. One record was required to contain documentation that the client was given the opportunity to request reconsideration of the decision terminating treatment. The facility failed to notify the client of an opportunity to request reconsideration of a decision terminating treatment in client record #5.
Client #5 was admitted into treatment on August 28, 2013 and was involuntarily terminated from the project on October 6, 2013. There was no documentation of written notification to the client, or of an opportunity to request reconsideration of a decision terminating treatment at the time of the licensing inspection. The house manager explained that the form was given to the client, but there was no documentation that the patient was given written notification.
The findings were reviewed with the house manager and were not disputed.
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Plan of Correction
1)Program Supervisor trained all staff on November 8th, 2013 about the administrative discharge form and its requirements. A copy of this form is placed in the client's chart and a copy is given to the client. This form indicates that the client has 10 days to appeal their discharge.
2)Program Supervisor will complete chart audits on all administratively discharged clients and assure that a copy of the administrative discharge form is included in the chart. Program Supervisor will review the findings with the Division Director during monthly program meetings. |
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
Based on the review of client records, the facility failed to document that work done by the client at the project as an integral part of the treatment and rehabilitation plan in three of six client records.
The findings include:
Six records were reviewed on October 21, 2013. Verification of work as an integral part of the treatment and rehabilitation plan was required in six client records. The facility did not document work as an integral part of the treatment and rehabilitation plan in client records #2, 5, and 6.
Client #2 was admitted on September 11, 2013. The preliminary treatment plan was completed on September 11, 2013 and the comprehensive treatment plan was completed on September 20, 2013. Both treatment plans failed to document the work done by the client at the project as an integral part of the treatment and rehabilitation plan.
Client #5 was admitted on August 28, 2013, and was discharged on October 6, 2013. The preliminary treatment plan was completed on August 28, 2013 and the comprehensive treatment plan was completed on September 5, 2013. Both treatment plans failed to document the work done by the client at the project as an integral part of the treatment and rehabilitation plan.
Client #6 was admitted on August 8, 2013, and was discharged on September 7, 2013. The preliminary treatment plan was completed on August 8, 2013 and the comprehensive treatment plan was completed on August 16, 2013. Both treatment plans failed to document the work done by the client at the project as an integral part of the treatment and rehabilitation plan.
The findings were reviewed with the facility director and were not disputed.
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Plan of Correction
1)Program Supervisor conducted a training with the facility counselors on 11/8/13. Counselors were given direction to make sure that work therapy was included as part of the treatment plans.
2)Program Supervisor will complete monthly chart audits to review compliance. Program Supervisor will review chart audit findings during the monthly QI/UR meeting. |