INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 29, 2016 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:
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Plan of Correction
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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.
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Observations
The facility failed to document written acknowledgement by the client that they were notified of their rights in ten of ten records reviewed on November 29, 2016.
Ten records were reviewed and required documentation of client rights. There was no documentation that the client was informed that the project, facility of clinical director may temporarily remove portions of the records prior to the inspection, if determined detrimental; reason for removal would be documented in the client's record; 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decision to remove information and that the client had the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their record in client records # 1, 2, 3, 4, 5,6, 7, 8, 9 and 10.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director of the Gaudenzia Erie Inc. Sharon Office will add to the client handbook a detailed statement outlining a clients right to access their records. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
The facility failed to document a psychosocial evaluation in five of ten client records reviewed on November 29, 2016.
Ten records were reviewed and all ten required psychosocial evaluations. There were no psychosocial evaluations documented in client records # 3, 4, 5, 9 and 10.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Program Director will review paperwork timeframes for psychosocial evaluations with all clinical staff. A psychosocial evaluation will be completed by the fourth individual session for each client. This will be reviewed monthly by the program director/clinical supervisor during monthly QI/PI |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
The facility failed to include the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan five in of eight client records reviewed on November 29, 2016.
Ten client records were reviewed. Eight were reviewed for comprehensive treatment plans. Client records, # 2, 3, 4, 5 and 7 did not document the type and frequency of treatment and rehabilitation services.
These findings were reviewed with facility staff during the inspection process.
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Plan of Correction
Program Director will review the treatment plan with each clinical staff member, highlighting the section that includes information regarding the frequency of treatment services. Clinicians will note the frequency of treatment on each treatment plan. This will be monitored during monthly file inspection by the program director/clinical supervisor and reported during monthly program improvement meetings. |
709.93(a) 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:
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Observations
The facility failed to document a complete client record that included progress notes and/or case consultation notes in three of ten client records reviewed on November 29, 2016.
Ten record were reviewed. Five records were reviewed as open clients and five records were reviewed as discharged clients. Ten records were reviewed for progress notes. Five records were reviewed for case consultation notes.
Client records # 2 and 3 did not document progress notes for sessions listed on the record of service.
Client record # 10 was a discharged client. There was no documentation of a case consultation note.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will provide supervision for each clinical staff to review expectations of documenting progress notes and case consultation notes. This will be monitored by the program director/clinical supervisor during monthly chart reviews and reviewed at the agencies monthly program improvement meeting. |
709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
The facility failed to provide a physician's signature on treatment plans and treatment plan updates in four of four client records reviewed on November 29, 2016.
Ten client records were reviewed. Four of the ten client records were required to have a physician's signature on the treatment plans and treatment plan updates. There was no physician's signature on the treatment plans and/or treatment plan updates in client records # 3, 4, 7 and 9.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Gaudenzia Erie Inc. Division Director will insure a contract with a local physician to review treatment plans and/or treatment plan updates is established. The Program Director will monitor that treatment plans are signed by a physician during monthly chart reviews and report concerns during monthly program improvement meetings. |