INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 11, 2008 through June 12, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Vantage House 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 July 11, 2008.
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Plan of Correction
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709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of client records, the facility failed to follow their written policies and procedures on completing physical examinations on each client in three of eleven client records reviewed. Physical examinations were completed late, as per facility policy, in client records #2, 3 and 11.
Based on a review of client records, the facility failed to document a complete physical examination in five of eleven client records reviewed. Client record #1 was missing the physician's signature. Client records #2, 3, 4 and 5 were missing the physician's impressions. Client record #5 was missing the client's vital signs and general appearance.
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Plan of Correction
The facility will adhere to the current written policies and procedures regarding completing physical examinatins on each client within the required time frame.The nurse and Program Director will meet with the Family Health Clinic and explain the importance of each client having a physical within the identified time frame. This will be effective immediately.
Person Responsible: Nurse
Person Responsible for monitoring:
Program Director
The facility will provide a complete physical on every client including the physician's signature, the physician's impressions and the client's vital signs and general appearance. The nurse will contact the family health clinic to review these missing items with the nurses and doctors at the facility.
Person Responsible: Nurse
Person Responsible for monitoring: Program Director |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a complete psychosocial evaluation in six of eleven client records reviewed, #4, 5, 6, 8, 9 and 11. Client records #4, 5, 8, 9 and 11 included client reported or historical information on the client's strengths. Client record #4 was missing potential or available client support systems . Client record #6 included client reported information rather than clinical impressions regarding client support systems. Client records #4 and 5 were missing the client's preferred coping mechanisms. Coping mechanisms were not identified in client record #6. Negative factors that might affect treatment were client reported or historical in client records #5, 8 and 9. The client's attitude toward treatment was missing in client records #4 and 8.
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Plan of Correction
The facility will provide a completed psychosocial document on each client. Information will include client's potential, and available client support systems, clinical impressions regarding client support systems, and client's preferred coping mechanisms. The client's attitude toward treatment will also be included. These changes will be effective immediately.
A clinical training has been scheduled for July 22 to assist clinical staff in reporting clinical impressions in the assessment portion of the psychosocial.
Person Responsible: Clinical Supervisor
Person Responsible for monitoring: Program Director |