INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the December 1, 2011 licensure renewal inspection. The follow-up inspection was conducted on May 11, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Gaudenzia Erie Inc. / Community 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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709.52(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 client records, the facility failed to document that counseling services were provided according to the individual treatment and rehabilitation plan in three of five client records.
The findings include:
Six residential treatment and rehabilitation client records were reviewed on May 11, 2012. The individual treatment and rehabilitation plans were reviewed in five of the client records and all five required that counseling services be provided according to the type and frequency specified on the plan. Client records # 2, 3 and 4 did not include documentation that counseling services were provided as per the individual treatment and rehabilitation plan.
Client #2 was admitted on March 12, 2012 and the individual treatment and rehabilitation plan was developed with the client on March 22, 2012. According to the individual treatment and rehabilitation plan, individual counseling is to be provided bi-weekly and groups are provided daily. Client #2 had individual counseling sessions on 3/12/12, 3/16/12, 3/22/12 and 3/30/12. No individual counseling sessions were documented for the month of April 2012.
Client #3 was admitted on April 11, 2012 and the individual treatment and rehabilitation plan was developed with the client on April 21, 2012. According to the individual treatment and rehabilitation plan, individual counseling is to be provided bi-weekly and groups are provided daily. Client #3 had individual counseling sessions on 4/12/12, 4/13/12 and 4/16/12. No individual counseling sessions were documented since 4/16/12.
Client #4 was admitted on January 26, 2012 and discharged on April 26, 2012. The individual treatment and rehabilitation plan was developed with the client on February 10, 2012. According to the individual treatment and rehabilitation plan, individual counseling is to be provided bi-weekly and groups are provided daily. Client #4 had individual counseling sessions on 1/26/12, 2/1/12, 2/3/12, 2/5/12, 2/10/12 and 2/29/12. No individual counseling sessions were documented for the months of March and April 2012.
An interview with the clinical supervisor took place on May 11, 2012 at which time it was confirmed that the facility was short staffed and not up to date on documentation.
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Plan of Correction
Program Supervisor will train and review requirements for individual counseling session documentation including the frequency of documented sessions.
Program Supervisor will complete monthly chart audits specific to individual counseling sessions and report findings in the monthly QI/UR meeting. |
709.53(a)(3) LICENSURE Records of Service
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:
(3) Record of services provided.
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Observations
Based on a review of client records, the facility failed to document a complete chronological listing of the various specific services provided to each individual client in four of five client records.
The findings include:
Six client records were reviewed on May 11, 2012. The record of service was reviewed in five client records. All five client records required the completion of a record of services provided. The record of services provided was incomplete in client records #2, 3, 4 and 5.
Client #2 was admitted to treatment on March 12, 2012. Progress notes were completed for individual sessions occurring on 3/12/12, 3/16/12, 3/22/12 and 3/30/12 as well as group sessions occurring on 3/31/12, 4/4/12, 4/5/12, 4/10/12, 4/23/12, 4/26/12, 4/29/12 and 4/30/12; however, none of these sessions were documented on the record of services. In addition, the record of service for the week of April 22-28, 2012 was not documented.
Client #3 was admitted to treatment on April 11, 2012. Progress notes were completed for individual sessions occurring on 4/12/12, 4/13/12 and 4/16/12 as well as group sessions occurring on 4/23/12, 4/29/12 and 4/30/12; however, none of these sessions were documented on the record of services. In addition, the record of service for the week of April 22-28, 2012 was not documented.
Client #4 was admitted to treatment on January 26, 2012. Progress notes were completed for individual sessions occurring on 1/26/12, 2/1/12, 2/3/12, 2/5/12, 2/10/12 and 2/29/12 as well as group sessions occurring on 4/4/12, 4/5/12, 4/23/12 and 4/26/12; however, none of these sessions were documented on the record of services.
Client #5 was admitted to treatment on January 25, 2012 and discharged on March 5, 2012. Progress notes were completed for individual sessions occurring on 1/25/12, 1/31/12, 2/2/12, 2/6/12, 2/15/12, 2/22/12, 2/28/12 and 3/5/12; however, none of these sessions were documented on the record of services.
An interview with the clinical supervisor took place on May 11, 2012 at which time it was confirmed that the facility was short staffed and not up to date on documentation.
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Plan of Correction
Program Supervisor will train all staff about the record of service and documenting services provided correctly and in a timely manner.
Program Supervisor will complete monthly chart audits specifically looking at the record of service.
Program Supervisor will review monthly chart audit findings in the QI/UR monthly meeting. |
709.53(a)(5) LICENSURE Progress Notes
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:
(5) Progress notes.
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Observations
Based on a review of client records, the facility failed to document progress notes after each significant client contact in four of five client records.
The findings include:
Six client records were reviewed on May 11, 2012. The progress notes were reviewed in five client records. Progress notes completed after each significant client contact were required in all five client records reviewed. Client Records # 2, 3, 4 and 5 did not include progress notes after each significant contact.
Client #2 was admitted to treatment on March 12, 2012. Group sessions took place on 3/13/12, 3/14/12, 3/15/12, 3/16/12, 3/20/12, 3/22/12, 3/26/12, 3/27/12, 3/28/12, 3/29/12, 4/11/12, 4/13/12, 4/18/12, 4/19/12, 4/20/12, 5/3/12 and 5/4/12 according to the record of service; however, there were no corresponding progress notes for these group sessions in client record #2.
Client #3 was admitted to treatment on April 11, 2012. Group sessions took place on 4/11/12, 4/17/12, 4/18/12, 4/19/12, 4/20/12, 5/1/12, 5/2/12, 5/3/12, and 5/4/12 according to the record of service; however, there were no corresponding progress notes for these group sessions in client record #3.
Client #4 was admitted to treatment on January 26, 2012 and discharged on April 26, 2012. Group sessions took place on 1/26/12, 1/27/12, 2/2/12, 2/3/12, 2/6/12, 2/7/12, 2/9/12, 2/10/12, 2/15/12, 2/21/12, 2/23/12, 2/24/12, 2/28/12, 3/2/12, 3/7/12, 3/8/12, 3/9/12, 3/13/12, 3/14/12, 3/15/12, 3/16/12, 3/22/12, 3/27/12, 3/28/12, 3/29/12, 3/30/12, 4/3/12, 4/11/12, 4/17/12, 4/18/12, 4/19/12 and 4/20/12 according to the record of service; however, there were no corresponding progress notes for these group sessions in client record #4.
Client #5 was admitted to treatment on January 25, 2012 and discharged on March 5, 2012. Group sessions took place on 1/25/12, 1/27/12, 2/6/12, 2/8/12, 2/9/12, 2/15/12, 2/16/12, 2/24/12, and 3/2/12 according to the record of service; however, there were no corresponding progress notes for these group sessions in client record #5.
An interview with the clinical supervisor took place on May 11, 2012 at which time it was confirmed that the facility was short staffed and not up to date on documentation.
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Plan of Correction
Program Supervisor will train all staff in regards to proper documentation of progress notes after each significant client interaction.
Program Supervisor will audit client charts monthly to review that all client interactions have been documented appropriately.
Program Supervisor will report chart audit findings in the monthly QI/UR meeting. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document a discharge summary within seven days of discharge in three of four client records.
The findings include:
Four discharged outpatient client records were reviewed on May 11, 2012. A discharge summary, which is to be completed within seven days of discharge, per facility policy, was required in all four client records. The facility did not document a discharge summary within seven days of discharge in client records # 11, 13 and 14.
Client #11 was admitted to residential treatment and rehabilitation on March 30, 2012 and was discharged on April 19, 2012. A discharge summary was due to be completed by April 26, 2012. The discharge summary documented in client record #11 was completed on April 27, 2012.
Client #13 was admitted to residential treatment and rehabilitation on February 28, 2012 and was discharged on March 12, 2012. A discharge summary was due to be completed by March 19, 2012. The discharge summary documented in client record #13 was completed on March 22, 2012.
Client #14 was admitted to residential treatment and rehabilitation on February 24, 2012 and was discharged on April 27, 2012. A discharge summary was due to be completed by May 4, 2012. The discharge summary documented in client record #14 was completed on May 7, 2012.
An interview with the clinical supervisor took place on May 11, 2012 at which time the aforementioned information was confirmed.
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Plan of Correction
Program Supervisor will train all clinical staff about discharge summaries including required time frames of completion.
Program Supervisor will complete monthly chart audits specific to discharge summary completion.
Program Supervisor will report results of monthgly chart audits in the monthly QI/UR meeting. |