INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 21, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Division of Accountability and Program Improvement. 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.
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Plan of Correction
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709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
The facility failed to document an informed and voluntary consent from the client prior to the disclosure of information to the funding entity in two of five client records reviewed on September 21, 2018.
Client # 1 was admitted May 16, 2018 and discharged July 24, 2018.
Client # 4 was admitted May 9, 2018 and discharged August 17, 2018.
The findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Program Director will train all administrative and clinical staff on intake procedures and requirements related to informed and voluntary consent. This training will be completed by 11/5/2018.
Program Director/Clinical Supervisor will complete monthly audits starting November 2018 to ensure informed and voluntary consents are completed. |
709.52(a) LICENSURE Individual TX and REHAB Plan
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:
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Observations
The facility failed to document an individual treatment plan that included the type and frequency of treatment and rehabilitation services in four of five residential client records reviewed on September 21, 2018.
Client # 1 was admitted May 16, 2018 and discharged July 24, 2018. The individual treatment plan was completed on May 25, 2018.
Client # 2 was admitted April 23, 2018 and discharged June 11, 2018. The individual treatment plan was completed on May 3, 2018.
Client # 3 was admitted June 18, 2018 and discharged August 22, 2018. The individual treatment plan was completed on July 6, 2018.
Client # 5 was admitted June 27, 2018. The individual treatment plan was completed on July 17, 2018.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director/Clinical Supervisor will train all clinical staff on treatment plans including type and frequency on treatment plans by 11/10/18
Program Director/Clinical Supervisor will complete monthly audits to ensure compliance with type and frequency of treatment services on treatment plans.
These chart audits will begin November 2018. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
The facility failed to document a treatment plan update at least every thirty days in two of five residential client records reviewed on September 21, 2018.
Client # 3 was admitted June 18, 2018 and discharged August 22, 2018. The individual treatment plan was completed on July 6, 2018. No treatment plan updates were documented.
Client # 5 was admitted June 27, 2018. The individual treatment plan was completed on July 17, 2018. The treatment plan update was not documented until August 24, 2018.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the 2017 annual inspection.
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Plan of Correction
Program Director/Clinical Supervisor will train all clinical staff on treatment plans updates and required timeframes by 11/10/18.
Program Director/Clinical Supervisor will complete monthly audits to ensure compliance with treatment plan updates and required timeframes.
These chart audits will begin November 2018. |