INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 5, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia (Pottsville) 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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709.92(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 policy and procedures and client records, the facility failed to document treatment plan updates every 60 days, as per facility policy, in two of six client records.
The findings include:
Eight client records were reviewed on June 5, 2013. Per facility policy, treatment plan updates will be completed every 60 days. Treatment plan updates were required in six client records. Two client records were not yet due for treatment plan updates. The facility failed to document treatment plan updates every 60 days in client records # 1 and 4.
Client # 1 was admitted into treatment on November 1, 2012. The comprehensive treatment plan was completed on February 7, 2013. A treatment plan update was due to be completed no later than April 7, 2013. There was no documentation of a treatment plan update in client record # 1, at the time of the review on June 5, 2013..
Client # 4 was admitted into treatment on December 26, 2012.. The comprehensive treatment plan was completed on January 16, 2013.. The first treatment plan update was due to be completed no later than March 16, 2013 and was not completed.
The facility director was interviewed and confirmed these treatment plan updates were not completed within the required 60 day time frame.
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Plan of Correction
An all staff in service training will be held on July 19, 2013 to address clinical staff on treatment management procedures specific to the treatment planning process. All staff will be directed to update treatment plans every 60 days or sooner. Staff will be directed to document progress on previous goals. The Clinical Supervisor will review treatment plans for compliancy during the CQI process monthly. Clinical staff will be monitored monthly in regular supervisory sessions. |
709.93(a)(8) LICENSURE Client records
709.93. 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document case consultations as per facility policy in three of six client records.
The findings include:
Eight client records were reviewed on June 5, 2013. Six of the eight client records were required to document case consultations. Per agency policy, case consultations are to be completed every ninety days. Case consultations were not completed in client records # 2, #5, and #6.
Client #1 was admitted to outpatient treatment on November 1, 2012. A case consultation was due to be completed by May 07, 2013. The case consultation was not documented.
Client #5 was admitted to outpatient treatment on January 22, 2013 and. A case consultations was due to be completed by May 14, 2013. The case consultation was not documented.
Client #6 was admitted to outpatient treatment on January 4, 2013. A case consultations was due to be completed by May 7, 2013. The case consultation was not documented.
The findings were confirmed with the facility director.
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Plan of Correction
An all staff in service training will be held on July 19, 2013 to address clinical staff on treatment management procedures specific to case consults. All staff will be directed to update case consults every 90 days or sooner. The Clinical Supervisor will review case consults for compliancy during the CQI process monthly. Clinical staff will be monitored monthly in regular supervisory sessions. The Program Director will review compliance through the QI and UR reports on a monthly basis. |
709.93(a)(9) LICENSURE Client records
709.93. 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to document goals with time frames in the aftercare plan in two of two client records.
The findings include:
Eight client records were reviewed on June 5, 2013. Aftercare plans were required in two client records. The facility did not document goals with time frames in the aftercare plan in client records #7 and 8
Client # 7 was admitted on December 11, 2012 and discharged on February 20, 2013. No goals with time frames were documented on the aftercare plan.
Client #8 was admitted on November 23, 2012 and discharged on march 12, 2013. No goals with time frames were documented on the aftercare plan.
These findings were confirmed by the facility director.
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Plan of Correction
An all staff in service training will be held on July 19, 2013 to address clinical staff on treatment management procedures specific to aftercare plans. All staff will be directed to complete an aftercare plan on discharged clients. Each aftercare plan shall include documentated goals for the client to continue working on with a specified time frame. The Clinical Supervisor will review and only sign off on a completed document. For those failing to comply, those plans will be returned to the assigned clinician for completion. Clinical staff will be monitored monthly in regular supervisory sessions. The Program Director will review compliance through the QI and UR reports on a monthly basis. |