Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on November 16-20, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, Gaudenzia Erie Inc. 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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Observations
Based on a review of client records on November 16-20, 2020, the facility failed to document treatment plan updates within the regulatory timeframe in client #'s 2, 3, 5, 6 and 7.
Client #2 was admitted on July 2, 2020 and was still active at the time of the inspection. A treatment plan was completed on August 3, 2020 and the next update was due no later than October 3, 2020; however, the update was completed on October 29, 2020.
Client #3 was admitted on July 23, 2020 and was still active at the time of the inspection. A treatment plan was completed on July 23, 2020 and the next update was due no later than September 23, 2020; however, the update was completed on October 22, 2020.
Client #5 was admitted on June 15, 2020 and discharged on October 5, 2020. A treatment plan update was completed on July 13, 2020 and the next update was due no later than September 13, 2020; however, there was no update documented in the record at the time of the inspection.
Client #6 was admitted on May 26, 2020 and discharged on August 25, 2020. A treatment plan was completed on May 26, 2020 and the next update was due no later than July 26, 2020; however, there was no update documented in the record at the time of the inspection.
Client #7 was admitted on April 15, 2020 and discharged on August 3, 2020. A treatment plan was completed on May 21, 2020 and the next update was due no later than July 21, 2020; however, there was no update documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will review timelines for documenting treatment plan updates during individual and group supervision. During the CQI process the treatment plans will be reviewed for timeliness and quality during monthly chart audits. Findings of these audits will be reviewed during monthly supervision. |