INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on March 14, 2018 by staff from the Division of Accountability and Program Improvement.. Based on the findings of the on-site complaint investigation, Gaudenzia Common Ground was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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709.52(a)(1) LICENSURE Short/Long term TX Goals
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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
A review of client records were conducted on March 14, 2018. Based on this review, the facility failed to develop an individual treatment plan that contained short and long-term goals for treatment as formulated by both staff and client.
Client #1 was admitted on August 25, 2016. Client #1's treatment plan, completed on August 30, 2016 was not signed by the client. There was no documentation available to verify that the client participated in the development of this treatment plan.
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Plan of Correction
Counselors are required to meet with their clients to collaborate and formulate objectives, goals, and actions steps prior to completing a resident's treatment plan. The counselor is required to review each treatment plan with their clients and have them sign the treatment plans to indicate a review
occurred and the client is in agreement with the plan. The Program Supervisor will be responsible for meeting with all clinicians by July 1st 2018 to discuss the process above. The Program Supervisor will also be responsible for conducting weekly and monthly audits to ensure staff and residents are signing their treatment plan. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. 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
A review of client records was conducted on March 14, 2018. Based on this review, the facility failed to provide counseling to a client on a regular and scheduled basis.
Client #1 was admitted on August 25, 2016. Client #1's treatment plan, completed on August 30, 2016, indicated that the client would receive one individual session per week. There was no documentation available to verify that the client received any individuals while in treatment.
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Plan of Correction
Counselors are expected to meet with their clients 1 x a week as per policy and licensing. Each session is to be documented and recorded. The Program Supervisor will be conducting a clinical supervisory session with all the clinicians by July 1st 2018 to review the above information. The Program Supervisor will be responsible for conducting ongoing weekly and monthly audits on charts to ensure residents are receiving 1-1 session at least every seven days. The Program Director will be responsible for conducting weekly community meetings with all residents to receive feedback on them receiving weekly 1-1 sessions. |