INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 13, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Gaudenzia Sunbury 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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709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
Based on a physical plant inspection on June 13, 2018, the facility facility failed to ensure that all hard copy patient records were kept in locked storage containers, and that there was no ability of unauthorized persons to gain access to such records.
The records were located in a storage room behind the administration office where Christmas Decorations and other unrelated items were being stored with client records in boxes that were not secured.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Effective 6-13-18 all client identifying documentation was relocated by Administrative Manager to a second locked room in the designated storage area. Monthly facility runs will be completed by supervisory staff to ensure all identifying information is secured behind double locks. |
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
Based on a review of client records, the facility failed to provide documentation of client rights in the client record for clients #3 and #4.
Client #3 was admitted on 03/19/18 and was still an active client at the time of the inspection. The client rights form was not signed by the client.
Client #4 was admitted on 04/03/18 and was still an active client at the time of the inspection. The client rights form was not signed by the client and there was no documentation on whether the client was offered a copy.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 6-22-18, Clinical Supervisor reviewed records # 3 and # 4 and determined that both clinical charts were electronic and hard copy paper records. Both client # 3 and # 4 had signed the client bill of rights in the paper chart. The papers were not part of the review that day. On 7-27-18 a clinical meeting will review the client bill of rights within the electronic health records system. Staff will be reminded to complete as part of the intake process. Clinical Supervisor will complete monthly quality control chart audits to ensure compliance. |
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 review of five Outpatient client records, the facility failed to document a Consent to Treatment in two of five records reviewed.
Client # 3 was admitted on 03/19/18 and was still an active client at the time of the inspection. There was no signature documented on the consent to treatment form in the client record.
Client #4 was admitted on 04/03/18 and was still an active client at the time of the inspection. There was no signature documented on the consent to treatment form in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 6-22-18, Clinical Supervisor reviewed records # 3 and # 4 and determined that both clinical charts were electronic and hard copy paper records. Both client # 3 and # 4 had signed the consent to treatment in the paper chart. The papers were not part of the review that day. On 7-27-18 a clinical meeting will review the consent to treatment within the electronic health records system. Staff will be reminded to complete as part of the intake process. Clinical Supervisor will complete monthly quality control chart audits to ensure compliance. |
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 on a review of five Outpatient client records, the facility failed to document comprehensive treatment plans that were developed with the client and did not provide frequency of counseling sessions in two of five records reviewed.
Client #3 was admitted on 03/19/18 and was still an active client at the time of the inspection. The treatment plan developed on 04/02/18 only stated 1:1 sessions which does not identify frequency and there was no documentation the treatment plan was developed with the client.
Client #4 was admitted on 04/03/18 and was still an active client at the time of the inspection. The treatment plan developed on 05/29/18 does not provide documentation that it was developed with the client,
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The electronic treatment plan form is currently undergoing revision to provide space to specify both type and frequency of interventions as well as prompts to remind the clinician to address this area. These revisions will be completed and fully implemented by 7/31/18. In addition, during all clinical meeting 7-27-18 staff will be reminded that all initial and comprehensive treatment plans must be developed with the client. The client will sign on the day of development. Program management will ensure that treatment plans are properly utilized through ongoing monthly chart audits. |
709.42(b)(2) LICENSURE Preliminary Treatment Plan
709.42. Project management.
(b) The intake project or treatment service providers shall have a written procedure for the performance of the following functions:
(2) Preparation of a preliminary treatment plan utilizing appropriate available service resources and listing the services to be provided. This plan shall be developed in cooperation with and agreed to by the intake project or treatment service provider and the client. The service plan shall also include referral to services not specifically for drug and alcohol clients; for example, legal services and dental services for which the client may be eligible.
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Observations
Based on a review of two Intake, Evaluation, and referral client records, The facility failed to document a preliminary treatment plan providing notification to the client of outside resources available to in two records reviewed.
Client #1 was admitted on 06/07/18 and was still an active client at the time of the inspection.
Client #2 was admitted on 06/04/18 and was still an active client at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 7-27-18 during the clinical meeting, preliminary treatment plan will be reviewed to include utilizing appropriate available service resources and listing the services to be provided. Staff will also be reminded that the preliminary plan is to be developed with the client, agreed upon and signed by the client that day and that resources can include non drug and alcohol related services. Client # 1 and # 2 charts will be reviewed by facility Clinical Supervisor by 8-1-18 to ensure that current treatment plans address outside resources if deemed necessary. Clinical Supervisor will complete monthly quality control chart audits to ensure compliance. |
709.42(h) LICENSURE Expeditious intake process
709.42. Project management.
(h) The intake process shall proceed expeditiously to avoid discouragement and should not exceed a period of 48 hours.
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Observations
Based on a review of two Intake, Evaluation and Referral records, the facility failed to complete the intake process within 48 hours in two of two applicable records reviewed.
Client #1 was admitted to Intake, Evaluation and Referral on June 7, 2018 and was still an active Intake, Evaluation and Referral client at the time of the inspection, June 19, 2018. An intake was begun on June 7, 2018 with another appointment scheduled for June 20, 2018.
Client #2 was admitted to Intake, Evaluation and Referral on June 4, 2018 and was still an active Intake, Evaluation and Referral client at the time of the inspection. An intake was performed on June 4, 2018 with another appointment scheduled for June 11, 2018. Additionally, there was no documentation of the 2nd appointment in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Currently the electronic health record system is undergoing revisions. A client record of service will be added to the electronic chart enabling all showed services, cancelled or rescheduled to be observed at a glance. This form will be developed by the Quality Improvement Director by 9-1-18. In addition, by 9-1-18 the intake/evaluation and referral time allotted per client will be expanded to ensure that the intake process is expeditious and should occur within 48 hours. Program management will monitor to ensure compliance. |