INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on June 21, 2017 by staff from the Division of Accountability and Program Improvement and the Division of Program Licensure. Based on the findings of the on-site complaint investigation,Gaudenzia Common Ground 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
A review of client records was conducted on June 21, 2017. Based on this review, the facility failed to assure that counseling services were provided according to individual treatment and rehabilitation plans.
Client #1, an active client, completed a comprehensive treatment plan on June 5, 2017. This plan indicated that Client #1 was to receive one individual counseling session each week. Client #1 received only two documented individual counseling sessions on June 2, 2017 and June 6, 2017.
The findings were reviewed with facility staff during the complaint investigation.
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Plan of Correction
All residents entering treatment will receive individual sessions within a seven day period each week beginning from date of admission. The clinical supervisor will be responsible for meeting with all clinicians to train them on proper procedures by 7/26/17. The Program Supervisor will be responsible for monitoring and implementing procedures, during weekly clinical supervision held each Wednesday,to ensure counselors are conducting individual session weekly. |
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
A review of client records was conducted on June 21, 2017. Based on this review, the facility failed to provide a complete client record on an individual which includes information relative to the client's involvement with the project. This shall included progress notes.
Client #1, an active client, had an incomplete client record. A review of Client #1's record indicated only one progress note for group therapy dated June 5, 2017.
The findings were reviewed with facility staff during the complaint investigation.
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Plan of Correction
The Program Supervisor will be responsible for collecting group feedback forms, facilitated by clinical staff, by the end of each week to ensure group notes are completed and filed in a timely manner. The Program Supervisor will be responsible for training 2nd and 3rd shift House managers to assist with proper filing of feedback group notes. The Program Supervisor will be responsible for overseeing group notes are filed and documented on a record of services sheet when completed. |