INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 24-25, 2017, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Erie Inc. Corry Satellite Office 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 all of their rights in six of six client records reviewed during the onsite inspection.
There was no documentation that the client was informed that the project director, facility director or clinical director may temporarily remove portions of the records prior to the inspection, if determined it may be detrimental to treatment; the reason for removal would be documented in the client's record; that the 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decision to remove information and that the client had the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their record in client records # 1, 2, 3, 4, 5 and 6.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
Division Director will review and adjust agency policy as needed to ensure all required client rights are listed in rights that are reviewed with clients upon admission. Division Director will complete this review by 11/14/2017.
Division Director will review agency policy/client rights with the Program Director by 11/17/2017.
Program Director will review updated policy/client rights with all staff by 11/21/2017.
Staff will begin using updated policy/client rights with all clients starting 11/22/2017.
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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 facility records conducted during the onsite inspection, the facility failed to provide counseling according to client treatment plans in four of six applicable records.
Client #1 was admitted for treatment on 07/14/2017, and was an active client during the onsite inspection. The client's treatment plan dated 07/14/2017, and treatment plan update dated 08/18/2017, both read that the client is to have individual counseling once weekly and group counseling once weekly, but the last documented individual counseling session was 07/14/2017, and the last documented group counseling session was 09/27/2017.
Client #3 was admitted for treatment on 06/28/2017, and was discharged on 09/20/2017. The client's treatment plan dated 06/28/2017, reads that the client was to have group counseling once weekly, but the only documented groups counseling sessions in July of 2017 were 07/20/2017, and 07/27/2017, and there were no documented group counseling sessions in September of 2017.
Client #4 was admitted for treatment on 05/01/2017, and was discharged on 09/15/2017. The client's treatment plan dated 06/19/2017, and treatment plan update dated 08/07/2017, both read that the client was to have group counseling once weekly, but there are no documented group counseling sessions for the client.
Client #6 was admitted for treatment on 06/22/2017, and was discharged on 09/22/2017. The client's treatment plan dated 06/29/2017, and treatment plan update dated 07/20/2017, both read that the client was to have individual counseling once weekly and group counseling once weekly, but there are no documented counseling sessions from 07/07/2017, through 08/09/2017, and from 08/11/2017, through 08/22/2017.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Program Director will meet with all clinical staff and review treatment plans and the importance of making sure identified services are being provided as stated on the treatment plan. Program Director will complete this meeting by 11/23/2017.
Program Director will complete monthly chart audits, starting in November 2017, to ensure services documented on the treatment plans are being provided as stated.
Program Director will report findings from the monthly chart audits in the agencies monthly quality improvement meeting starting on 12/20/2017. Any identified issues will be discussed with a solution focused approach to improve any identified issues. |
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 a review of client records conducted during the onsite inspection, the faility failed to document client follow ups after the clients were discharged in two of four applicable records.
Client #3 was admitted for treatment on 06/28/2017, and discharged on 09/20/2017.
Client #5 was admitted for treatment on 01/12/2017, and discharged 09/05/2017.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Program Director will review the agency policy/procedure with all staff as it relates to client follow ups. this review with staff will occur by 11/23/2017.
Administrative Coordinator will review client follow ups monthly starting November 30th, 2017 to ensure all are being completed appropriately and timely. Administrative Coordinator will report any ongoing issues with follow ups to the program Director. |