INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 21-22, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Inc. Harrisburg Concept 90 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, the facility failed to inform the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, in three of three client records reviewed.
The findings include:
Three client records that required documentation of termination letters were reviewed on April 21-22, 2014. The facility failed to document written notification of a decision to involuntarily terminate the client's treatment in client records # 4, 8 and 9.
Client #4 was terminated from treatment on April 1, 2014. At the time of the inspection there was no documentation of a termination letter.
Client #8 was terminated from treatment on April 11, 2014. At the time of the inspection there was no documentation of a termination letter.
Client #9 was terminated from treatment on January 16, 2014. At the time of the inspection there was no documentation of a termination letter.
The clinical supervisor confirmed the findings.
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Plan of Correction
Program staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project and include the reason for termination.
A form has been developed for this specific purpose and will be completed by clinical staff as required.
The Program Supervisor shall review with staff and implement the form's use by 5/23/14 and monitor continued compliance via monthly chart audits. |
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 the review of client records, the facility failed to document a complete client record on each individual in three out of ten client records reviewed.
The findings include:
Ten client records were reviewed on April 21-22, 2014. Ten complete client records were required. The facility failed to document a complete client record for client's # 4, 9 and 10.
Client record # 4 did not include documentation of a complete discharge summary.
Client record # 9 did not include documentation of a follow-up contact.
Client record # 10 did not include documentation of a follow-up contact.
The findings were confirmed with the clinical supervisor.
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Plan of Correction
Program staff shall assure that they document a complete client record on each individual including the timely completion of a discharge summary and documentation of follow up contact according to organizational policy and licensing regulations.
Forms have been developed for this specific purpose and will be completed by clinical staff as required.
The Program Supervisor has reviewed with staff and implemented the form's use effective 7/22/14.
The Program and Clinical Supervisors will monitor continued compliance via monthly chart audits and report audit findings in the monthly Continuous Quality Improvement Committee meeting.
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