INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 10 - 11, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Erie, Inc. - Crossroads 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 (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
The facility failed to document a complete release of information form prior to disclosure in three of eight client records reviewed on October 10 - 11, 2017.
Client #1 - A release of information, for the purpose of phone communication / drop off / visitation, was signed on 10-7-2017, but was blank for the person / agency.
Client #2 - A release of information for the purpose of phone communication / drop off / visitation, was signed on 4-5-2017, but was blank for the person / agency.
Client #4 - The record included a discharge summary for another client.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Program Director will review releases of information and the proper way to fully complete a release with all staff by 11/21/2017.
Program Director will review confidentiality guidelines with all staff and discuss the extreme importance in making sure client documents are always in the proper client file by 11/21/2017.
Program Director/Clinical Supervisor will complete monthly chart audits on 20% of the files to specifically look at releases of information and confidentiality issues. These audits will begin in November 2017.
Program Director/Clinical Supervisor will report any identified issues during the monthly chart audits in the agencies monthly quality improvement meetings. If any continued issues are identified solution focused discussions will occur in the quality improvement meeting. Audit results will begin to be reported during the quality improvement meeting on 12/20/2017. |
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
The facility failed to document written acknowledgement by the client that they were notified of all of their rights in eight of eight client records reviewed on October 10 - 11, 2017.
There was no documentation that the client was informed that the project, facility of clinical director may temporarily remove portions of the records prior to the inspection, if determined detrimental; reason for removal would be documented in the client's record; client has a right to appeal the decision to remove information and that the client had the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their record in client records # 1, 2, 3, 4, 5, 6, 7, and 8.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Division Director will review and adjust agency policy as needed to ensure all required client rights are listed in rights that are reviewed with clients upon admission. Division Director will complete this review by 11/14/2017.
Division Director will review agency policy/client rights with the Program Director by 11/17/2017.
Program Director will review updated policy/client rights with all staff by 11/21/2017.
Staff will begin using updated policy/client rights with all clients starting 11/22/2017. |
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
The facility failed to ensure counseling services were provided according to the individual treatment plan in two of five client records reviewed on October 11, 2017.
Client #4 and Client #5 were not provided individual sessions according the treatment plan.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will review proper documentation of treatment plans with all clinical staff by 11/21/2017. this will include reviewing the importance of following the documented treatment services with clients.
Program Director/Clinical Supervisor will complete monthly chart audits on 20% of the files to ensure that treatment services are documented appropriately and are also being provided as documented. These monthly chart audits will begin in November 2017.
Program Director/Clinical Supervisor will discuss audit findings in the agency monthly quality improvement meetings. these findings will begin being discussed in the quality improvement meeting scheduled for 12/20/2017. |
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
The facility failed to document a complete client record in two of five client records reviewed on October 11, 2017.
Client #5 - Missing documentation of a 4-20-2017 progress notes for a session listed on the record of service. Missing an entry on the record of service for an individual session on 5-4-2017.
Client #7 - Missing an entry on the record of service for an individual session on 9-29-2017.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will meet with all staff and review proper documentation of the record of service as well as the importance of making sure all items documented on the record of service are also documented in the files. This training with staff will occur by 11/21/2017.
Program Director/Clinical Supervisor will complete monthly chart audits on 20% of all client files specifically looking at the record of service and making sure all services are documented and that all services that are documented also have corresponding notes in the client record. These chart audits will begin in November 2017.
Program Director/Clinical Supervisor will discuss any ongoing issues with the record of service in the monthly quality improvement meeting starting 12/20/2017. |