INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 12 and 13, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Gaudenzia Together 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:
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Plan of Correction
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704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of the policy and procedure manual on May 21-24, 2019, the facility failed to follow their policy in regards to completion of the assessment of staff training needs. The Plan for Assessing Staff Training Needs policy stated "The training plan shall be ready for implementation effective Jan. 31st of each year." The overall training plan for the project was not completed until May 16, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program completion of the annual assessment of staff training needs. The Plan for Assessing Staff Training Needs will be ready for implementation effective Jan. 31st of each year.
The relevant Gaudenzia Policy has been revised to state that, "Program-level training needs assessments are due to the Training department by the end of January of each year. Upon receipt of the program-level annual assessments of staff training needs, the Director of Training and Education, in collaboration with the Project Director, will review the assessments in detail and develop a plan to address the training needs of the agency. The annual agency-wide training plan shall be ready for implementation no later than April 30th of each year." The Gaudenzia Director of Training and Education will ensure that this is completed within the designated timeframe each year.
The following persons will be responsible to ensure the corrective action is implemented:
Division Director
Program Director
Program Supervisor
Timeframe for Completion: April 30, 2020 |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records on June 12, 2019 and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee #7 received the minimum of six hours of HIV/AIDS training and at least four hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #7 was hired as a certified recovery specialist on December 27, 2016 and was due to have the communicable disease trainings no later than December 27, 2018. There was no documentation in the personnel record of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Employee #7 will receive the minimum of six hours of HIV/AIDS training on August 8, 2019 at Gaudenzia's Training Institute. The training is scheduled from 9am-1pm.
The Director of Training and Education will be ultimately responsible for ensuring that all staff (to include administrative staff) receive required HIV/AIDS with the 1st year of employment. Training department staff will review all staff files during the orientation process to ensure that this training is completed.
The Program Director will ensure that all new employees receive at least 6 hours of HIV/AIDS training; four hours of TB/STD and other health related topics within the regulatory timeframe per DDAP Policy 704.11 (c)(1).
The following persons will be responsible to ensure the corrective action is implemented:
Director of Training and Education
Division Director
Program Director
Program Supervisor
Timeframe for Completion: August 8, 2019 |
705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on a physical plant inspection on June 13, 2019, it was observed that the facility failed to maintain trash dumpsters in a manner to prevent the penetration of insects and rodents. The lids to the dumpsters were observed open with trash protruding out of the top.
The findings were reviewed with facility staff at the time of the inspection.
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Plan of Correction
The facility will maintain trash dumpsters in a manner to prevent the penetration of insects and rodents. The lids to the dumpsters will be monitored per DDAP Policy 705.2 (4)
House Managers who monitor the members taking out trash along with the kitchen staff will ensure that the lids are closed and monitored per the policy.
The following persons will be responsible to ensure the corrective action is implemented:
Division Director
Program Director
Program Supervisor
Food Service Manager
House Managers
Timeframe for Completion: June 13, 2019 |
705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on a physical plant inspection on June 13, 2019, it was observed the facility failed to maintain working exhaust fans in two bathrooms. The south side bathroom on the women's unit and the female bathroom on the third floor did not having working exhaust fans at the time of the inspection.
These findings were reviewed with facility staff at the time of the inspection.
This is a repeat citation from the July 26, 2018 inspection.
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Plan of Correction
The new exhaust fans have been ordered, however to date they have not been received.
The maintenance department will assure installation by August 1, 2019.
The Division Director and Maintenance Supervisor will be responsible for ensuring that the bathroom fans are installed.
Weekly safety reports and maintenance department reports will monitor compliance of policy 705.6 Bathrooms.
The following persons will be responsible to ensure the corrective action is implemented:
Division Director
Program Director
Maintenance Supervisor
Timeframe for Completion: August 1, 2019
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705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based upon a physical site inspection on June 13, 2019, the facility failed to maintain bathrooms in a clean and sanitary manner. A shower stall in the third floor female bathroom was observed to have two dirty bath mats and black grime around the perimeter of the shower floor.
These findings were reviewed with facility staff at the time of the inspection.
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Plan of Correction
On 7/20/19 the remaining mold and mildew in the shower will be removed after being power-washed. After the shower is cleaned it will be re-chalked. Another maintenance request was put in on 7/9/19 to have all of the shower's in the building power washed and cleaned on a monthly basis.
The program staff and maintenance department will monitor the cleanliness of the bathrooms and the members will continue with the weekly General Inspection (GI) of their living areas which includes the bathrooms.
Persons Responsible: Division Director, Program Director and Maintenance Supervisor.
Timeframe for Completion: July 21, 2019
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705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records on June 3, 2019, employee #1 was not trained in fire extinguisher use upon hire. Employee #1 was hired on March 4, 2019 and was still employed at the time of the inspection. There was no documentation that the employee received the training as of the date of this inspection June 12, 2019.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director completed this training on 6/7/19 and documentation of this has been placed in his file. All relevant staff within the HR and Training departments will review the DDAP 705.10 (c) (4) - 705.28 (c) (4) regulations by 7/31/19, and as the head of the Training department, the Director of Training and Education will be ultimately responsible for ensuring that all staff (to include administrative staff) receive required fire extinguisher training upon hire. Training department staff will review all staff files during the orientation process to ensure that this training is completed.
Persons Responsible:
The Director of Training and Education |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based upon a review of personnel records on June 3, 2019, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies. Employee #1 was hired on March 4, 2019 and was still employed at the time of the inspection. There was no documentation in employee #1 ' s personnel record indicating that the employee had been trained on what to do during emergencies as of the date of this inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director completed this training on 6/7/19 and documentation of this has been placed in his file. All relevant staff within the HR and Training departments will review the DDAP 705.10 (c) (4) - 705.28 (c) (4) regulations by 7/31/19, and as the head of the Training department, the Director of Training and Education will be ultimately responsible for ensuring that all staff (to include administrative staff) receive required fire extinguisher training upon hire. Training department staff will review all staff files during the orientation process to ensure that this training is completed.
Persons Responsible:
Director of Training and Education
Date of Completion: 7/31/19 |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on the review of seven client records on June 12 - 13, 2019, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in client records, #1, 2, 4, 5, 6 and 7.
Client #1 was admitted on November 21, 2018 and discharged on December 11, 2018. A consent to release information form to the funding source was signed and dated on November 23, 2018, which was two days after client was admitted. During an interview with facility director, acknowledgement was made that the consent form should have been signed and dated the day of admission as billing would have begun on the day of admission.
Client #2 was admitted on March 11, 2019 and was still active at the time of the inspection. A consent to release information form to the funding source was signed and dated on April 12, 2019, which was thirty-one days after client was admitted. During an interview with facility director, acknowledgement was made that the consent form should have been signed and dated the day of admission as billing would have begun on the day of admission. In addition, two consent to release information forms to a laboratory and pharmacy were signed and dated on April 12, 2019. According to documentation in the client's record, faxes to the pharmacy was sent on March 11, March 13, March 20 and March 24, 2019. Urine screenings were sent to the laboratory on March 21, April 2 and April 11, 2019.
Client #4 was admitted on January 8, 2019 and discharged on April 29, 2019. A consent to release information form to the funding source was signed and dated on January 15, 2019, which was seven days after client was admitted. During an interview with facility director, acknowledgement was made that the consent form should have been signed and dated the day of admission as billing would have begun on the day of admission.
Client #5 was admitted on March 15, 2019 and discharged on May 23, 2019. A consent to release information form to the funding source was signed and dated on March 19, 2019. The expiration date on the form was the same date, March 19, 2019. No other consent to release information forms to the funding source were located in the client's record. During an interview with facility director, acknowledgement was made that a consent to release information form to the funding source should have been in the client's record.
Client #6 was admitted on January 4, 2019 and discharged on March 10, 2019. The client's record did not contain a consent to release information form for the funding source. During an interview with facility director, acknowledgement was made that a consent to release information form to the funding source should have been in the client's record as billing would have begun on the day of admission.
Client #7 was admitted on December 4, 2018 and discharged on March 18, 2019. The client's record did not contain a consent to release information form for the funding source. During an interview with facility director, acknowledgement was made that a consent to release information form the funding source should have been in the client's record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Together House Program will obtain an informed and voluntary consent from the client for the disclosure of specific information disclosed in the charts during admission. We will review all other current open charts and obtain an informed and voluntary consent form for them as needed. This has been in effect since July 17, 2019 and charts will be reviewed on a monthly basis during CQI.
On September 9, 2019 a Record-Keeping training will be facilitated to review the 4 PA Code 255.5 Confidentiality Request to Release Information Form and DOH Policy 709.28 (c)(1).
All Consent to Release Information Forms will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings and to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible:
Division Director
Program Director
Program Supervisor
Timeframe for Completion: September 9, 2019 |
709.28 (c) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of client records on June 12 - 13, 2019, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5(b) for releases of information in client record #'s 1, 4 and 5.
Client #1 was admitted on November 21, 2018 and discharged on December 11, 2018. A consent to release form was signed and dated on November 23, 2018 to the funding source that allowed for the release of the treatment plan.
Client #4 was admitted on January 8, 2019 and was discharged on April 29, 2019. A consent to release form was signed and dated on January 15, 2019 to the funding source that allowed for the release of the aftercare plan, treatment plan and medications. A second consent to release information form was signed and dated on January 15, 2019 to the same funding source that allowed for the release of medications.
Client #5 was admitted on March 15, 2019 and discharged on May 23, 2019. A consent to release form was signed and dated on March 19, 2019 to the funding source that allowed for the release of medications and the treatment plan.
These findings were reviewed with facility staff at the time of the inspection.
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Plan of Correction
The Gaudenzia Together House Program will obtain an informed and voluntary consent from the client for the disclosure of specific information disclosed in the current charts. The consent will be in writing and include, but not limited to specific information disclosed. This has been in effect since July 17, 2019 and charts will be reviewed on a monthly basis during CQI.
On September 9, 2019 a Record-Keeping training will be facilitated to review the Confidentiality Request to Release Information Form and DOH Policy 709.28(c)and PA Code 255.5. Projects and Coordinating Bodies: Disclosure of Client-Oriented Information.
All Consent to Release Information Forms will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings and to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible:
Division Director
Together House Program Director
Together House Supervisors
Timeframe for Completion: September 9, 2019 |
709.32 (c) (1) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication, including the documentation of the administration of medication:
(i) By individuals permitted to administer by Pennsylvania law.
(ii) When self administered by the client.
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Observations
Based on a review of two client records on June 13, 2019, the facility failed to document administration of medication by staff in accordance with physician's orders in two client records.
Client #8 was admitted on May 8, 2019 and was still active at the time of the inspection. There was no documentation on the medication administration record on June 6, 2019 of patient receiving his/her 9:00 pm dose of omeprazole 20 mg. In addition, there was no documentation of client receiving his/her 9:00 pm dose of Quetiapine 100mg on June 6 and 7, 2019.
Client #9 was admitted on May 10, 2019 and was still active at the time of the inspection. There was no documentation on the medication administration record on June 11, 2019 of patient receiving his/her 9:00 pm dose of trazodone 100mg.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Together House Medical Department will facilitate a daily audit of the Medication Administration Records (MARS) and the Nurse Manager will audit the MARS three (3) times a week.
The Medication Missed or Refusal Sheets will be completed daily by the nurse on duty and turned in to the clinical team during the Morning Meetings.
All members Open Charts will be monitored monthly during CQI Meetings.
Persons Responsible:
Nurse Manager
Medical Department Staff
Timeframe for Completion: July 20, 2019 |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records on June 12-13, 2019, the facility failed to document notification of the client in writing of his/her involuntary termination from the project in one client record.
Client #7 was admitted on December 4, 2018 and discharged on March 18, 2019.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Gaudenzia Together House Program will document notification of the client in writing of his/her involuntary termination from the project in one client record.
On September 9, 2019 a Record-Keeping training will be facilitated to review the Notification of Termination and DOH Policy 709.33.
All of the members who are discharged will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings and to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible:
Division Director
Together House Program Director
Together House Supervisors
Timeframe for Completion: September 9, 2019 |
709.51(b)(4) LICENSURE Consent to treatment
709.51. 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 on June 12 - 13, 2019, the facility failed to document a completed consent to treatment in four client records.
Client # 1 was admitted on November 21, 2018 and discharged on December 11, 2018. The consent to treat form for Gaudenzia Together House was not signed by the client.
Client #4 was admitted on January 8, 2019 and was discharged on April 29, 2019. The consent to treat form was signed and dated by the client on January 15, 2018, which was six days after admission.
Client #6 was admitted on January 4, 2019 and discharged on March 10, 2019. The consent to treat form in the client's record was not signed by the client.
Client #7 was admitted on December 4, 2018 and discharged on March 18, 2019. The consent to treat form in the client's record was not signed or dated by the client.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Gaudenzia Together House Program will document a completed Consent to Treatment in current Open Records.This has been in effect since July 17, 2019 and charts will be reviewed on a monthly basis during CQI.
On September 9, 2019 a Record-Keeping training will be facilitated to adhere by Policy and DOH Policy 709.33.
All of the members who are admitted will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings and to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible:
Division Director
Together House Program Director
Together House Supervisors
Timeframe for Completion: September 9, 2019
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709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of seven client records on June 12-13, 2019, the facility failed to document treatment plan updates within the regulatory timeframe in four client records reviewed.
Client #2 was admitted on March 11, 2019 and was still active at the time of the inspection. A treatment plan update was completed on April 16, 2019 and the next update was due no later than May 16, 2019; however, the next treatment plan update was on May 28, 2019.
Client #4 was admitted on January 8, 2019 and was discharged on April 29, 2019. A comprehensive treatment plan was completed on January 15, 2019 and an update was due no later than February 15, 2019; however, the update was completed on February 23, 2019.
Client #6 was admitted on January 4, 2019 and discharged on March 10, 2019. A comprehensive treatment plan was completed on January 9, 2019 and an update was due no later than February 9, 2019; however, there was no documentation of any updates being completed in the client's record.
Client #7 was admitted on December 4, 2018 and discharged on March 18, 2019. A comprehensive treatment plan was completed on December 15, 2018 and an update was due no later than January 15, 2019; however, there was no documentation of any updates being completed in the client's record.
These findings were reviewed with facility staff at the time of the inspection.
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Plan of Correction
The Gaudenzia Together House Program will review and update treatment plans within the regulatory guidelines as outlined in 709.52 Treatment and Rehabilitation Services. The long term member updated plan will be every 30 days; short term rehabilitation updated at least every 15 days.
On September 9, 2019 a Record-Keeping training will be facilitated to review the 709.52: Treatment and Rehabilitation services.
All of the members who are discharged will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings and to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible:
Division Director
Together House Program Director
Together House Supervisors
Timeframe for Completion: September 9, 2019
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709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of seven client records on June 12 - 13, 2019, there was no documentation the clients received counseling services according to their individual comprehensive treatment plan in seven records reviewed.
Client #1 was admitted on November 21, 2018 and discharged on December 11, 2018. The comprehensive treatment plan, dated November 26, 2018 indicated weekly group sessions. The record of service and progress notes indicated the client did not receive any group sessions while at the facility.
Client #2 was admitted on March 11, 2019 and was still active at the time of the inspection. The comprehensive treatment plan, dated March 11, 2019, indicated weekly group and individual sessions. The record of service and progress notes indicated the client received his/her first group session on April 11, 2019. In addition, the client did not receive individual sessions between March 21 - April 14, and April 26 - May 6, 2019.
Client #3 was admitted on May 6, 2019 and discharged on June 12, 2019. The comprehensive treatment plan, dated May 9, 2019, indicated weekly group and individual sessions. The record of service and progress notes indicated the client received one individual session on May 9, 2019 and did not receive any group sessions while at the the facility.
Client #4 was admitted on January 8, 2019 and was discharged on April 29, 2019. The comprehensive treatment plan, dated January 15, 2019, indicated weekly group and individual sessions. The record of service and progress notes indicated the client's first group session occurred on March 1, 2019. In addition, the client did not receive individual sessions between January 18-29 and February 24 - March 3, 2019.
Client #5 was admitted on March 15, 2019 and discharged on May 23, 2019. A comprehensive treatment plan update, dated April 10, 2019, indicated weekly individual sessions. The record of service and progress notes indicated the client did not receive individual sessions between April 18 - May 12, 2019.
Client #6 was admitted on January 4, 2019 and discharged on March 10, 2019. The comprehensive treatment plan, dated January 9, 2019, indicated weekly group and individual sessions. The record of service and progress notes indicated the client did not receive individual sessions between January 11 - 27, 2019 and group sessions from January 12 - February 3, 2019.
Client #7 was admitted on December 4, 2018 and discharged on March 18, 2019. The comprehensive treatment plan, dated December 15, 2018, indicated weekly group and individual sessions. The record of service and progress notes indicated the client received one individual session on December 5, 2018 and the client's first group session was on January 9, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Gaudenzia Together House Program will documentation the clients received counseling services according to their individual comprehensive treatment plan within the regulatory guidelines as outlined in 709.52
Treatment and Rehabilitation Services.
On September 9, 2019 a Record-Keeping training will be facilitated to review the 709.52: Treatment and Rehabilitation services.
All of the members files will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings and to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible:
Division Director
Together House Program Director
Together House Supervisors
Timeframe for Completion: September 9, 2019
. The long term member updated plan will be every 30 days; short term rehabilitation updated at least every 15 days.
On September 9, 2019 a Record-Keeping training will be facilitated to review the 709.52: Treatment and Rehabilitation services.
All of the members who are discharged will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings and to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible:
Division Director
Together House Program Director
Together House Supervisors
Timeframe for Completion: September 9, 2019
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709.53(a) LICENSURE Complete Client Record
709.53. 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:
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Observations
Based on a review of seven client records on June 12 - 13, 2019, the facility failed to provide a complete client record, which is to include case consults, aftercare plans, discharge summaries, follow-up information and documentation of work therapy, in client record #'s 1, 2, 3, 4, 5, 6 and 7.
Client #1 was admitted on November 21, 2018 and discharged on December 11, 2018. The client record did not contain documentation of work therapy.
Client #2 was admitted on March 11, 2019 and was still active at the time of the inspection. The client record did not contain documentation of work therapy.
Client #3 was admitted on May 6, 2019 and discharged on June 12, 2019. The client record did not contain documentation of work therapy.
Client #4 was admitted on January 8, 2019 and was discharged on April 29, 2019. The client record did not contain documentation of work therapy, a discharge summary, an aftercare plan and follow-up information.
Client #5 was admitted on March 15, 2019 and discharged on May 23, 2019. The client record did not contain documentation of work therapy, and a case consult.
Client #6 was admitted on January 4, 2019 and discharged on March 10, 2019. The client record did not contain documentation of work therapy, a discharge summary, an aftercare plan and follow-up information.
Client #7 was admitted on December 4, 2018 and discharged on March 18, 2019. The client record did not contain documentation of work therapy, a discharge summary, an aftercare plan and follow-up information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Gaudenzia Together House Program will provide a complete client record in all Open Charts, which is to include case consults, aftercare plans, discharge summaries, follow-up information and documentation of work therapy. This has been in effect since July 17, 2019 and charts will be reviewed on a monthly basis during CQI.
On September 9, 2019 a Record-Keeping training will be facilitated to review the DOH Policy 709.53 Complete Client Record.
All complete client records will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings and to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible:
Division Director
Together House Program Director
Together House Supervisors
Timeframe for Completion: September 9, 2019 |