INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 23, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gage House, LP 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
The facility failed to document written notification of involuntary termination in 2 of 2 client records.Seven client records were reviewed on June 23, 2017. Clients #4 and #5 were involuntarily terminated from treatment. There was no documentation that clients #4 and #5 were provided with a written notice of involuntary termination.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director met with forms committee to develop involuntary discharge form on 7/19/17. This form will be built into the electronic medical record and in use by 8/15/17. This form will be printed as documentation of written notice of involuntary discharge and given to clients upon leaving the facility. If the client's behavior or situation precludes the printing and offering of this form, it will be mailed. Clinical supervisor will complete chart monitors monthly to ensure compliance. |
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
The facility failed to document a complete client record, including follow up contact in 4 of 4 client records.Seven client records were reviewed on June 23, 2017. Four of the clients reviewed were discharged from the facility and required documentation of follow up contact. Client records # 4, 5, 6 and 7 did not include documentation of follow up contact.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director completed training with Gage House staff regarding documentation of follow up on 6/27/17. Follow up letters and/or calls will be completed as per agency policy guidelines, and documentation will occur in the electronic medical record upon their completion. Clinical supervisor will monitor charts for completion of follow up documentation. |