INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 29, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia West Shore 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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705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on an inspection of the facility's physical plant, the facility failed to ensure that exits from the facility were unobstructed.
The findings include:
A physical plant inspection was conducted on May 29, 2013 at around 11:30 AM. During the inspection, it was found that the exit from the conference room was locked and a key was needed to exit.
This was confirmed by the clinical supervisor.
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Plan of Correction
Effective immediately, the deadbolt on the door to egress from the conference room will remain unlocked during hours of operation.
To ensure compliance, facility runs will be made on all shifts by the Administrative staff and Program Supervisor to maintain an unobstructed exit. |
709.92(a) 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:
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Observations
Based upon a review client records and the facility's policies and procedures, the facility failed to develop individual treatment and rehabilitation plans as per their policy.
The findings include:
In reference to timelines for the comprehensive treatment plan the facility's policy states: The individualized treatment plan shall be completed by the third outpatient counseling appointment.
Twelve client records requiring documentation of individualized treatment plans were reviewed on May 29, 2013. Four out of twelve client records contained treatment plans that were completed late or were missing, specifically #'s 1, 3, 5, and 12.
Client #1 was admitted to treatment on March 5, 2013. As of the date of inspection, there was no documentation of a treatment plan for client #1.
Client #3 was admitted to treatment on March 7, 2013. As of the date of inspection, there was no documentation of a treatment plan for client #3.
Client #5 was admitted to treatment on February 19, 2013. The client's third counseling session was on March 26, 2013. The individualized treatment plan was not completed until April 2, 2013.
Client #12 was admitted to treatment on September 26, 2012 and discharged on January 4, 2013. The client's third counseling session was on October 19, 2012. The individualized treatment plan was not completed until November 13, 2012.
The findings were reviewed with the clinical supervisor during the exit interview.
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Plan of Correction
The Program Director and Program Supervisor will hold a staff meeting with all staff members to review Gaudenzia Policies and Procedures regarding time frames for completion of treatment plans. This will occur by July 1, 2013. The Program Supervisor will then monitor adherence to these policies through regular monthly audits of the clinical charts. The findings of these audits will be monitored as a part of the Continuous Quality Improvement process.
The Program Director will maintain oversight of these practices. |
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 client records and the facility's policies and procedures, the facility failed to document a treatment plan update in accordance with the facility's policies and procedures.
The findings include:
The facility's policy regarding treatment plan updates indicated that treatment and rehabilitation plans will be reviewed and updated at least every sixty days. The treatment plan update will include an assessment of the client's progress in relationship to stated goals.
Eight client records requiring treatment plan updates were reviewed on May 21, 2013. The treatment plan updates were deficient in three out of eight client records, specifically records #1, 3, and 4.
Client #1 was admitted on December 19, 2012. The treatment plan update which occurred on May 17, 2013 did not document the progress on goals for client #1.
Client #3 was admitted on October 2, 2012. A treatment plan update had occurred on December 12, 2012 and another was due by February 12, 2013. The treatment plan update was not documented until March 6, 2013.
Client #4 was admitted on February 11, 2013. The treatment plan update which occurred on March 28, 2013 did not document the progress on goals for client #4.
The findings were discussed with the facility director during the exit interview.
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Plan of Correction
Effective immediately, counselors will devise a treatment plan udpate within 60 days. They will also document progress or the lack thereof on the previous stated goals as outlined on the treatment plan.These will be reviewed by the Program Supervisor, prior to being signed, for compliance.
The Program Supervisor will also utilize a tracking system to establish end dates for treatment plans to ensure clinicians complete them in the required time frame.
Lastly, the Program Supervisor will monitor adherence through monthly chart audits. Outcomes will be discussed with clinicians in supervisory sessions.
The Program Director will be responsible for oversight. |