INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 18, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Gaudenzia, Inc. Outreach 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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709.92(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
Based on a review of client records conducted during the on-site inspection, the facility failed to properly document the frequency of services in 3 of 7 client records.
Client #1 was admitted on 9/26/17, and was active at the time of inspection. The client's individualized treatment plan dated 4/20/18, does not indicate frequency of counseling services to be provided.
Client #2 was admitted on 11/7/17, and was active at the time of inspection. The client's individualized treatment plan dated 5/22/18, does not indicate frequency of counseling services to be provided.
Client #3 was admitted on 7/31/17, and was active at the time of inspection. The client's individualized treatment plan dated 7/31/17, does not indicate frequency of counseling services to be provided.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
The electronic treatment plan form is currently undergoing revision to provide space to specify both type and frequency of interventions as well as prompts to remind the clinician to address this area. These revisions will be completed and fully implemented by 7/31/18. Program management will ensure that treatment plans are properly utilized through ongoing regular chart audits. |
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.
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Observations
Based on a review of 7 client records, 6 client records had treatment plan updates completed after the regulatory timeframe or missing at the time of the inspection.
Client #1 was admitted on 9/26/17 and was active at the time of inspection. A treatment plan update was completed 10/9/17 and the next update was due no later than 12/9/17. However, the next update was not completed until 2/20/18.
Client #2 was admitted on 11/7/17 and was active at the time of inspection. A treatment plan update was completed 2/8/18 and the next update was due no later than 4/8/18. However, the next update was not completed until 4/17/18.
Client #3 was admitted on 7/31/17 and was active at the time of inspection. A treatment plan was completed 7/31/17 and the update was due no later than 9/30/17. However, the next update was not completed at the time of inspection.
Client #4 was admitted on 3/16/17 and was discharged on 2/23/18. A treatment plan was completed 11/15/17 and the next update was due no later than 1/15/18. However, the next update was not completed until 1/23/18.
Client #6 was admitted on 9/13/17 and was discharged on 5/7/18. A treatment plan was completed 9/27/17 and the next update was due no later than 11/27/17. However, the update was not completed as of the date of the inspection.
Client #7 was admitted on 7/28/17 and was discharged on 3/16/18. A treatment plan was completed 7/28/17 and the next update was due no later than 9/28/17. However, the update was not completed as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director and Program Supervisor will meet with clinical staff to discuss the timeframe of treatment plans and the effectiveness of assuring that all treatment plans are updated in timely manners as required by the agency and licenses.
Moving forward the clinical documentation will be audited daily to assure that all treatment plans are completed timely and are in the clinical charts.
Program Director and Program Supervisor will audit the charts and discuss any discrepancies found during the audit in the clinical meeting. |