INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 20, 2015, by staff from the Department of Drug and Alcohol Programs, Program Licensure Division. Based on the findings of the on-site inspection, Gaudenzia West Shore 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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709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation in two of ten client records reviewed.
The findings include:
Ten client records requiring documentation of a psychosocial evaluation were reviewed on 5/20/2015. A psychosocial evaluation was not completed in accordance with the facility's policy in client records #2 and #6.
Client #2 was admitted on 9/2/2014 and discharged on 4/1/2015. A psychosocial evaluation was not documented in the client's record.
Client #6 was admitted on 11/14/2014 and discharged on 3/27/2015. A psychosocial evaluation was not documented in the client's record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The biopsychosocial evaluations for client records #2 and #6 will be completed by 7/1/15 and placed in each of the clients' records.
Effective immediately, the Program Supervisor will ensure that psychosocial evaluations will be completed within thirty (30) days or at the initial evaluation whichever applies.
Monthly chart audits will be conducted by the supervisor and outcomes discussed in weekly clinical meeting/supervisory sessions.
The Program Director will maintain oversight of this compliance.
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709.92(c) LICENSURE Treatment and rehabilitation services
709.92. 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 project failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plan in three of ten client records reviewed.
The findings include:
Ten client records were reviewed for counseling services on 5/20/2015. The project failed to ensure that clients received counseling services according to the client's individual treatment and rehabilitation plan in client records #1, #2, and #6.
Client #1 was admitted to treatment on 6/27/14 with a discharge date of 1/28/15. Client record #1 contained a treatment plan dated 7/27/2014 that identified the counseling services to be provided as individual therapy sessions 1 time biweekly. The client's record of service identified individual therapy sessions on 9/12/2014 and 11/14/2014. There was no indication on the Record of Service that the client cancelled or did not show up for a scheduled therapy.
Client #2 was admitted to treatment on 9/2/2014 with a discharge date of 4/1/2015. Client record #2 contained a treatment plan dated 10/30/2014 that identified the counseling services to be provided as individual therapy sessions 2-3 times per month. The client's record of service identified individual therapy sessions on 11/19/14, 1/20//15, and 2/19/15. There was no indication on the Record of Service that the client cancelled or did not show up for a scheduled therapy.
Client # 6 was admitted to treatment on 9/9/2014 with a discharge date of 11/26/2014. Client record #6 contained a treatment plan dated 1/14/2015 that identified the counseling services to be provided as individual therapy sessions 1-2 times per month. The client's records of service identified that there were no individual therapy sessions for the month of February 2015. There was no indication on the Record of Service that the client cancelled or did not show up for a scheduled therapy.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client record of services for client files #1, #2, and #6 will indicate the appropriate identified counseling services that were to be provided according to the treatment plans. This will be corrected by 7/1/2015.
Effective immediately, the Program Supervisor will ensure that the prescribed treatment services that are being recommended are provided and documented in the treatment plan and subsequent Client Record of Services.
QI chart audits will also be conducted on a monthly basis and outcome reviews will be made with each clinician following the week of the CQI meeting.
The Program Director will be responsible for oversight of compliance with the above standards. |