INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 18, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia, Inc. 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 21, 2009.
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Plan of Correction
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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of six personnel records, the facility failed to document CPR and first aid training to a sufficient number of staff persons.
Findings:
Six personnel records were reviewed on June 18, 2009. The facility did not document CPR and first aid training to a sufficient number of staff persons during the evening hours of operation.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on a physical plant tour, and an interview with the facility director, the facility failed to maintain the confidentiality of the client ' s identity.
Findings:
A physical plant inspection was conducted on June 18, 2009 at approximately 14:00. The client sign-in sheet, in the reception area, was observed to contain the first and last names of clients presently at the facility.
The facility director confirmed the practice of having all client ' s sign the sign-in sheet upon arrival.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on a review of seven client records, four of which were reviewed for intake procedures, the facility failed to document intake procedures to include, disclosure to the client, of the criteria for admission, treatment, completion and discharge in four of four client records.
Findings:
Seven client records were reviewed on June 18, 2009. Documentation of intake procedures was reviewed in four client records. The facility did not document disclosure to the client of the criteria for admission, treatment, completion and discharge in client records # 1, 2, 3 and 4.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on a review of seven client records, four of which were reviewed for consent to treatment, the facility failed to document the client ' s consent to treatment in three of four client records.
Findings:
Seven client records were reviewed on June 18, 2009. Documentation of the client ' s consent to treatment was reviewed in four client records. The facility did not document consent to treatment in client records # 1, 3 and 4.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of seven client records, four of which were reviewed for psychosocial evaluations, the facility failed to document a psychosocial evaluation by the second treatment session as per facility policy in three of four client records.
Findings:
Seven client records were reviewed on June 18, 2009. Psychosocial evaluations were reviewed in four client records. The facility did not document a psychosocial evaluation by the second treatment session, as stated in the projects policy manual in client records # 1, 2 and 4.
Client record #1 admission date 1/2/09, but psychosocial evaluation not documented at time of inspection.
Client record #2 admission date 1/26/09, but psychosocial evaluation not dated.
Client record #4 admission date 1/27/09, but psychosocial evaluation not dated.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of seven client records, the facility failed to document treatment plans to include type and frequency of treatment and rehabilitation services in three of four client records.
Findings:
Seven client records were reviewed on June 18, 2009. Treatment plans were reviewed in four client records. The facility did not document a treatment plan to include type and frequency of treatment and rehabilitation in client records 1, 2 and 3.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of seven client records, four of which were reviewed for treatment plan updates, the facility failed to document treatment plan updates that included an assessment of the client's progress to the stated goals in the comprehensive treatment plan, in four of four client records.
Findings:
Seven client records were reviewed on June 18, 2009. Treatment plan updates were reviewed in four client records. The facility did not document a treatment plan update to include an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan in client records # 1, 2, 3 and 4.
Client record #1 treatment plan updates documented on 3/11/09 and 5/11/09 did not include an assessment of progress.
Client record #2 treatment plan update documented on 5/19/09 did not include an assessment of progress.
Client record #3 treatment plan updates documented on 3/24/09, 4/28/09 and 5/12/09 did not include an assessment of progress.
Client record #4 treatment plan updates documented on 3/10/09 and 5/18/09 did not include an assessment of progress.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of seven client records, four of which were reviewed for case consultations, the facility failed to document case consultation notes every 90 days, in three of four client records.
Findings:
Facility policy titled: "CASE CONSULTATION" dated January 2009, stated:
"Each client ' s progress should be reviewed at least quarterly [90 days] at a case conference consisting of representatives from the various client service components."
Seven client records were reviewed on June 18, 2009. Case consultation notes were reviewed in four client records. The facility did not document a case consultation note at least quarterly in client records # 1, 2 and 4.
Client record # 1, admission date 1/2/09, but case consultation note not documented at time of inspection.
Client record # 2, admission date 1/26/09, but case consultation note not documented at time of inspection.
Client record # 4, admission date 1/27/09, but case consultation note not documented at time of inspection.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 seven client records, three required documentation that follow-ups had been conducted. The facility failed to document follow-up information in three of three client records.
Seven client records were reviewed on June 18, 2009. Follow-up information was required in three client records. The facility did not document follow-up within thirty days after discharge, as stated in the projects policy manual, in client records # 5, 6 and 7.
Client record #5 discharge date 3/24/09, but follow-up was documented on 6/18/09.
Client record #6 discharge date 4/23/09, but follow-up was documented on 6/18/09.
Client record #7 discharge date 4/22/09, but follow-up was documented on 6/17/09.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |