INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 7, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia, 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 and a plan of correction is due on November 20., 2009.
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Plan of Correction
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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on the review of CPR certification records and a review of the staff schedule, the facility failed to ensure that at least one person certified in CPR was onsite during all hours of operation.
The findings include:
CPR certification records and the staff schedule were reviewed on October 7, 2009. The facility was required to document CPR certification to a sufficient number of staff persons. The facility did not have sufficient staff members with CPR certification on the Monday evening shift.
On Mondays, during the hours of 5:00 PM to 8:00 PM, the facility did not have at least one person on site certified in CPR.
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Plan of Correction
As of 11/13/09 there will be at least one person certified in CPR at the site. We will continue to monitor and ensure that all staff are certified. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on the review of client records, the facility failed to assure that counseling services were provided according to the individual treatment plan in three of four client records.
The findings include:
Seven client records were reviewed on October 7, 2009. Four of the seven records were reviewed for documentation of counseling according to the treatment plan. The facility did not document missed counseling sessions in a progress note or on the record of service in client records # 1, 3 and 4.
In client record #1, the treatment plan dated 7/17/09 and the treatment plan update dated 9/15/09 stated individual counseling sessions one time weekly, but individual session progress notes were only documented on 7/1/09, 7/24/09, 8/20/09, 8/27/09 and 9/24/09.
In client record #3, the treatment plan dated 9/14/09 stated individual counseling sessions one time weekly, but individual session progress notes were only documented on 9/9/09 and 9/14/09.
In client record # 4, the treatment plan dated 9/17/09 stated individual counseling sessions one time weekly, but individual session progress notes were only documented on 9/17/09 and 9/24/09.
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Plan of Correction
As of 11/19/09 all clinical staff have been trained to make sure that they are addressing missed sessions with clients. They will document it in their notes and will see that it is logged on the record of service. Clinical Supervisor and Program Director will review charts to ensure that this is being followed. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on the review of client records, the facility failed to document a case consultation in two of two client records.
The findings include:
Seven client records were reviewed on October 7, 2009. Two of the seven records required documentation of a case consultation. The facility did not document a case consultation at least every 90 days in client records # 1 and 6.
Client record #1 was admitted to the program on 6/30/09, but a case consultation was not documented at the time of inspection.
Client record #6 was admitted to the program on 5/7/09, but the case consultation was documented on 8/18/09.
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Plan of Correction
As of 11/19/09 all clinical staff have been retrained to ensure that case consultations are completed within the proper time frames. Clinical Supervisor and Program Director will be doing chart audits to ensure that case consultations are completed within 90 days. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on the review of client records, the facility failed to document an aftercare plan in two of two client records.
The findings include:
Seven client records were reviewed on October 7, 2009. Two of the seven records required documentation of an aftercare plan. The facility did not document an aftercare plan approximately one month prior to discharge as stated in the projects policy manual in client records # 6 and 7.
The project ' s policy titled " Aftercare Policy " states, " The formal Aftercare Plan is completed by the counselor and client approximately one month prior to discharge " .
Client record # 6 successfully completed the program and was discharged 8/27/09, but an aftercare plan was not documented at time of inspection.
Client record # 7 successfully completed the program and was discharged 9/3/09, but an aftercare plan was not documented at time of inspection.
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Plan of Correction
As of 11/19/09 all clinical staff have been trained to complete an aftercare plan on clients completing treatment one month prior to discharge. Clinical Supervisor and Program director will be reviewing charts to ensure that policy is followed. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on the review of client records, the facility failed to document follow-up information in two of two client records.
The findings include:
Seven client records were reviewed on October 7, 2009. Two of the seven records required documentation of follow-up information. The facility did not document follow-up information within thirty days after discharge as stated in the projects policy manual in client records # 6 and 7.
The project ' s policy titled " Follow-Up Policy " states, " Where clients are not referred after discharge, the administrative coordinator or their designee will call the client in 30 days. Contact will be logged in the follow-up log binder. "
Client record #6 was discharged on 8/27/09, but follow-up was not documented at time of inspection.
Client record #7 was discharged on 9/3/09, but follow-up was not documented at time of inspection.
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Plan of Correction
As of 11/10/09 staff has been trained to make follow up calls as per Gaudenzia Follow-Up Policy whereas, clients that have been discharged and follow up calls have been made within 30 days. Contact will be logged and placed in a follow up binder. Administrative Coordinator will review and Program Director will also audit so the program has a check and balance system to follow this. |