INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on October 17-19, 2017, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the 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:
|
Plan of Correction
|
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
|
Observations
The facility failed to document written acknowledgement by the client that they were notified of all of their rights in seven of seven client records reviewed on October 17-19, 2017.
There was no documentation that the client was informed that the project director, facility director or clinical director may temporarily remove portions of the records prior to the inspection, if determined it may be detrimental to treatment; the reason for removal would be documented in the client's record; that the client has a right to appeal the decision to remove information and that the client had the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their record in client records # 1, 2, 3, 4, 5, 6 and 7.
These findings were reviewed with facility staff as part of the licensing process.
|
Plan of Correction
Division Director reviewed agency policy and procedures on 11/14/2017 and ensured all required items related to client rights were included for future use.
Division Director will review the policy and procedure regarding client rights with all clinical staff in the facility by 12/08/2017.
Division Director/Program Director will ensure The reviewed policy and procedure pertaining to client rights will be implemented into the facilities intake process by 12/09/2017.
Program Director will complete monthly chart audits beginning in December 30, 2017 ensuring the client rights policy and procedure has been reviewed, signed and completed, and that clients were offered a copy of the policy and procedure.
|
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 clients records conducted during the onsite inspection, the facility failed to update client treatment plans at least every 60 days in three of seven records reviewed.
Client #1 was admitted for treatment on 03/10/2017. The client's treatment plan had an update dated 08/04/2017, but the next update was not completed until 10/14/2017.
Client #5 was admitted for treatment on 01/05/2017. The client's treatment plan had an update dated 04/24/2017, but the next update was not completed until 07/03/2017.
Client #7 was admitted for treatment on 03/24/2017. The client's treatment plan was dated 04/11/2017, but the treatment plan was not updated until 06/29/2017.
These findings were reviewed with facility staff as part of the inspection process.
|
Plan of Correction
Program Director will review Treatment Plan requirements and time frames with all clinical staff by 12/08/2017.
Program Director will complete monthly chart audits beginning in December 2017 to ensure that Treatment Plans and Treatment Plan updates are completed in a timely manner.
Program Director will report the results of the monthly chart audit in the agencies monthly quality improvement meeting starting January 17, 2018. |