INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 29-30, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Washington 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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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 May 29-30, 2013 the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment.
The findings include:
Two client records that required termination letters were reviewed. The facility failed to notify the client, in writing, of a decision to involuntarily terminate treatment at the project in two out of two records.
The findings were confirmed by the facility director.
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Plan of Correction
The Program Director will review chart documentation on all charts prior to the discharge of each resident.
Residents whose traetment has been terminated will recieve a letter of termination of treatment prior to their discharge. The letter of termination of treatment will also be placed in the residents chart prior to the discharge of that resident. |
709.51(b)(3)(i) LICENSURE Medical histories
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on the review of seven client records, the facility failed to document medical histories in one of three client records.
The findings include:
Seven client records were reviewed on May 29-30, 2013. Medical histories were required in three client records. The facility did not document medical histories by the first individual session as required by the project's policy in client record #6.
Client #6 was admitted March 8, 2013. There was no medical history completed for this client.
The facility director confirmed the findings.
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Plan of Correction
The Psychosocial Assessment policy will be revised to add the following language: "Gaudenzia programs may accept a completed biopsychosocial history from an external agency, provided that it has been completed within 6 months prior to the date of admission to the Gaudenzia program. The Gaudenzia staff member will review the history with the individual, making note of any new or updated information, and initialing each page. A new Gaudenzia Biopsychosocial Assessment will then be completed within required timeframes."
Also, the Standardized Client Records policy will be revised to add the following statement: "Gaudenzia has developed and maintains standardized client records via standardized record forms (except as noted in other areas of this policy manual)."
These changes will be reviewed, approved by the board, and implemented by July 31st, 2013.
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709.51(b)(3)(ii) LICENSURE Drug & Alcohol History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on the review of seven client records, the facility failed to document drug or alcohol histories in one of three client records.
The findings include:
Seven client records were reviewed on May 29-30, 2013. Drug or alcohol histories were required in three client records. The facility did not document drug or alcohol histories by the first individual session as required by the project's policy in client record #6.
Client #6 was admitted March 8, 2013. There was no drug or alcohol history completed for this client.
The facility director confirmed the findings
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Plan of Correction
The Psychosocial Assessment policy will be revised to add the following language: "Gaudenzia programs may accept a completed biopsychosocial history from an external agency, provided that it has been completed within 6 months prior to the date of admission to the Gaudenzia program. The Gaudenzia staff member will review the history with the individual, making note of any new or updated information, and initialing each page. A new Gaudenzia Biopsychosocial Assessment will then be completed within required timeframes."
Also, the Standardized Client Records policy will be revised to add the following statement: "Gaudenzia has developed and maintains standardized client records via standardized record forms (except as noted in other areas of this policy manual)."
These changes will be reviewed, approved by the board, and implemented by July 31st, 2013.
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709.51(b)(3)(iii) LICENSURE Personal History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on the review of seven client records, the facility failed to document personal histories in one of three client records.
The findings include:
Seven client records were reviewed on May 29-30, 2013. Personal histories were required in three client records. The facility did not document personal histories by the first individual session as required by the project's policy in client record #6.
Client #6 was admitted March 8, 2013. There was no personal history completed for this client.
The facility director confirmed the findings
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Plan of Correction
The Psychosocial Assessment policy will be revised to add the following language: "Gaudenzia programs may accept a completed biopsychosocial history from an external agency, provided that it has been completed within 6 months prior to the date of admission to the Gaudenzia program. The Gaudenzia staff member will review the history with the individual, making note of any new or updated information, and initialing each page. A new Gaudenzia Biopsychosocial Assessment will then be completed within required timeframes."
Also, the Standardized Client Records policy will be revised to add the following statement: "Gaudenzia has developed and maintains standardized client records via standardized record forms (except as noted in other areas of this policy manual)."
These changes will be reviewed, approved by the board, and implemented by July 31st, 2013.
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