INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on 5/27/2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia at Sunbury 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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709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in one of four client records.
The findings include:
Two client records requiring written notification to the client of the facility's decision to involuntarily terminate the client's treatment were reviewed on 5/27/2015. The facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the facility in client record # 4.
Client # 4 was admitted on 11/24/2014 and was involuntarily terminated from the facility on 4/17/2015 for continuously not showing up for scheduled counseling sessions. There was no documentation of written notification of the facility's decision to involuntarily terminate the client's treatment as of the date of the on-site inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An all staff in service training was held on June 19, 2015 to address clinical staff on treatment management procedures specific to discharge paperwork which includes the letter of termination. An updated termination letter was emailed to all staff on 5-10-15 and added to the master discharge packet. Administrative staff will review the chart to verify completion during the monthly CQI process. Clinical staff will be monitored monthly in regular supervisory sessions.
Client # 4 was mailed notice of termination letter on 6-15-15.
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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 a review of client records, the project failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plan in five of twelve client records reviewed.
The findings include:
Twelve client records were reviewed for counseling services on 5/27/2015. The project failed to ensure that clients received counseling services according to the client's individual treatment and rehabilitation plan in client records # 1, 3, 6, 9 and 12.
Client record # 1 contained a treatment plan dated 4/1/2015 that identified the counseling services to be provided as individual therapy sessions 1 time per week. There were no individual therapy sessions scheduled for the client the weeks 4/26/2015 - 5/23/2015.
Client record # 3 contained a treatment plan dated 4/2/2015 that identified the counseling services to be provided as individual therapy sessions 1 time per week. There were no individual therapy sessions scheduled for the client the weeks 5/10/2015 - 5/23/2015.
Client record # 6 contained a treatment plan dated 1/1/2015 that identified the counseling services to be provided as individual therapy sessions 1 time per week. There were no individual therapy sessions scheduled for the client the weeks 1/1/2015 - 2/28/2015.
Client record # 9 contained a treatment plan dated 2/17/2014 that identified the counseling services to be provided as individual therapy sessions 1 time per week. There were no individual therapy sessions scheduled for the client the weeks 3/1/2015 - 3/7/2015 and 3/15/2015 - 3/21/2015.
Client record # 12 contained a treatment plan dated 3/24/2015 that identified the counseling services to be provided as individual therapy sessions 1 time per week. There were no individual therapy sessions scheduled for the client the weeks 4/26/2015 - 5/23/2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An all staff in service training will be held on June 19, 2015 to address clinical staff on treatment management procedures specific to assuring that counseling services are provided according to the individual and treatment plan updates. All staff will be directed to schedule clients according to their treatment recommendation and document weekly on the client record of service. Any deviation from the set course of treatment will also be documented on the record of service. The Clinical Supervisor will review treatment plans recommendations and compare it to the record of service for compliancy during the CQI process monthly. Clinical staff will be monitored monthly in regular supervisory sessions. |
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
Based on the review of client records, the facility failed to ensure that a complete record was documented in six of twelve client records reviewed.
The findings include:
Twelve client records requiring documentation of a complete client record were reviewed on 5/27/2015. The facility failed to document a complete record in client records # 1, 2, 4, 5, 8 and 12.
Client # 1 was admitted on 12/29/2014 and was still an active client at the time of the inspection. There was no documentation of a record of service for May 2015.
Client # 2 was admitted on 1/19/2015 and was still an active client at the time of the inspection. There was no documentation of a record of service for May 2015.
Client # 4 was admitted on 11/24/2014 and discharged on 4/17/2015. There was no documentation of a discharge summary in the client's record.
Client # 5 was admitted on 10/6/2014 and discharged on 3/13/2015. There was no documentation of a discharge summary in the client's record.
Client # 8 was admitted on 12/4/2014 and was still an active client at the time of the inspection. There was no documentation of progress notes for the individual sessions that the client attended on 2/12/2015, 2/19/2015, 3/5/2015, 3/12/2015, 3/26/2015, 4/2/2015 and 4/9/2015.
Client # 12 was admitted on 10/10/2014 and was still an active client at the time of the inspection. There was no documentation of progress notes for the individual sessions that the client attended on 1/9/2015, 1/16/2015, 1/20/2015, 1/27/2015, 2/17/2015, 2/24/2015, 3/10/2015, 3/24/2015, 4/6/2015 and 4/21/2015. Furthermore, there was no documentation of a record of service for May 2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An all staff in service training will be held on June 19, 2015 to address clinical staff on treatment management procedures specific to client records. All staff will be directed to update the client record of service per the treatment plan recommendation and to include all attendance cancellations and/or no shows. Each month the client is active in treatment will be reflected by client record of service. Clinicians will be directed to support each service by written progress note. Upon discharge clinicians will be directed to complete all required paperwork within the 7 day timeframe. The Clinical Supervisor will review charts monthly to ensure compliance through the CQI process. Staff will be reminded to review the facility mock chart. Clinical staff will be monitored monthly in regular supervisory sessions.
Charts currently missing log notes, record of service and/or discharge paperwork will be brought up to date by 6-30-15. Verification of documentation will be completed by Clinical Supervisor or Administrative Manager and updated in the CQI system. |