This report is a result of an administrative review conducted on September 10-12, 2019, September 17-18, 2019, and an on-site licensure renewal inspection conducted on September 19-20, 2019, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Erie Inc. Edniboro Sattelite 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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Observations
Based on a review of client records conducted during the on-site inspection, the facility failed to update client treatment plans at least once every 60 days in two applicable client records.
A total of six client records were reviewed during the on-site inspection, and two of the records reviewed required treatment plan updates.
Client #2 was admitted for treatment on October 10, 2018, and discharged on April 17, 2019. The client's individualized treatment plan was completed October 10, 2018, but it was not updated until January 2, 2019, and the next update was not completed until March 20, 2019.
Client #4 was admitted for treatment on February 20, 2019, and discharged on July 30, 2019. The client had a treatment plan update completed on May 21, 2019, but the next update was not completed until July 30, 2019.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
Clinical Supervisor will review timelines for updated treatment plans with clinical staff.
Clinicians will make contact with clients when they missed appointments to ensure they remain in compliance with treatment plan time frames.
Clinical Supervisor will monitor treatment plan updates in monthly program improvement meeting to ensure compliance. |