INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 1 - 2, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia, Inc. Outreach 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)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records, the facility failed to document histories which included the client's medical, drug/alcohol history and personal history in five of seventeen records reviewed.
The findings include:
Seventeen client records were reviewed on June 1-2, 2015, for documentation of the client's medical history, drug/alcohol history and personal history. The facility failed to document those histories in client records, # 1, 3, 4, 10 and 16.
Client # 1 was admitted to the facility on March 12, 2015, and was still an active client at the time of inspection. The facility failed to document a medical, drug/alcohol and personal history for client # 1 at the time of inspection.
Client # 3 was admitted to the facility on October 1, 2014, and was still an active client at the time of inspection. The facility failed to document a drug/alcohol and personal history for client # 3 at the time of inspection.
Client # 4 was admitted to the facility on October 1, 2014, and was still an active client at the time of inspection. The facility failed to document a drug/alcohol and personal history for client # 4 at the time of inspection.
Client # 10 was admitted to the facility on March 27, 2015, and was still an active client at the time of inspection. The facility failed to document a medical, drug/alcohol and personal history for client # 10 at the time of inspection.
Client # 16 was admitted to the facility on October 17, 2014 and discharged on February 9, 2015. The facility failed to document a drug/alcohol and personal history for client # 16's duration of treatment.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will meet with clinical staff (on 6/19/15) to review time frames for completing clinical documentation, specifically biopsychosocial history interview assessments. As per stated protocol, this document must be completed within the first 30 days of treatment (as outlined in the policy and procedure manual - policy 709.51 b 6). This will be overseen by Division Director for compliance by random chart audit on a quarterly basis (at minimum). |
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 six of seventeen records reviewed.
The findings include:
Seventeen client records were reviewed on June 1 - 2, 2015, for documentation of a psychosocial evaluation. The facility failed to document a psychosocial evaluation in six of seventeen client records, # 1, 3, 4, 10, 13 and 16.
Client # 1 was admitted to the facility on March 12, 2015, and was still an active client at the time of inspection. The facility failed to document a psychosocial evaluation as of the date of the licensing inspection.
Client # 3 was admitted to the facility on October 1, 2014, and was still an active client at the time of inspection. The facility failed to document a psychosocial evaluation as of the date of the licensing inspection.
Client # 4 was admitted to the facility on October 1, 2014, and was still an active client at the time of inspection. The facility failed to document a psychosocial evaluation as of the date of the licensing inspection.
Client # 10 was admitted to the facility on March 27, 2015, and was still an active client at the time of inspection. The facility failed to document a psychosocial evaluation as of the date of the licensing inspection.
Client # 13 was admitted to the facility on September 22, 2014 and discharged on January 29, 2015. The facility failed to document a psychosocial evaluation for client # 13's duration of treatment.
Client # 16 was admitted to the facility on October 17, 2014 and discharged on February 9, 2015. The facility failed to document a psychosocial evaluation for client # 16's duration of treatment.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will meet with clinical staff (on 6/19/15) to review time frames for completing clinical documentation, specifically biopsychosocial evaluations. As per stated protocol, this document must be completed within the first 30 days of treatment (as outlined in the policy and procedure manual - policy 709.51 b 6). This will be overseen by Division Director for compliance by random chart audit on a quarterly basis (at minimum). |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document a preliminary treatment and rehabilitation plan in four of seventeen records reviewed.
The findings include:
Seventeen client records were reviewed on June 1 - 2, 2015, for documentation of a preliminary treatment and rehabilitation plan. The facility failed to document a preliminary treatment plan in client records, # 2, 8, 13 and 16.
Client # 2 was admitted to the facility on October 15, 2014, and was still an active client at the time of review. The facility failed to document a preliminary treatment plan during intake for client # 2 as of the date of the licensing inspection.
Client # 8 was admitted to the facility on October 6, 2014, and was still an active client at the time of review. The facility failed to document a preliminary treatment plan during intake for client # 8 as of the date of the licensing inspection.
Client # 13 was admitted to the facility on September 22, 2014 and discharged on January 29, 2015. The facility failed to document a preliminary treatment plan for client # 13's duration of treatment.
Client # 16 was admitted to the facility on October 17, 2014 and discharged on February 9, 2015. The facility failed to document a preliminary treatment plan for client # 16's duration of treatment.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will meet with clinical staff (on 6/19/15) to review time frames for completing clinical documentation. One topic of discussion will be the documentation that is required within the initial session which is to include a Preliminary Treatment Plan. As outlined in the Policy and Procedure Manual (policy # 709.51 b 7). This will be overseen by Division Director for compliance by random chart audit on a quarterly basis (at minimum). |
709.93(a) 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:
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Observations
Based on a review of client records, the facility failed to document a complete client record in twelve of seventeen records reviewed.
The findings include:
Seventeen client records were reviewed on June 1 - 2, 2015. The facility failed to document a complete client record that included a record of services provided and a case consultation note in client records, # 1, 3, 4, 9, 10, 11, 12, 13, 14, 15, 16 and 17.
Client # 1 was admitted to the facility on March 12, 2015, and was still an active client at the time of inspection. The facility failed to document a complete client record which included a record of services provided in client record # 1.
Client # 3 was admitted to the facility on October 1, 2014, and was still an active client at the time of inspection. The facility failed to document a complete client record which included a record of services provided in client record # 3.
Client # 4 was admitted to the facility on October 1, 2014, and was still an active client at the time of inspection. The facility failed to document a complete client record which included a record of services provided in client record # 4.
Client # 9 was admitted to the facility on March 27, 2015, and was still an active client at the time of inspection. The facility failed to document a complete client record which included a record of services provided in client record # 9.
Client # 10 was admitted to the facility on March 27, 2015, and was still an active client at the time of inspection. The facility failed to document a complete client record which included a record of services provided in client record # 10.
Client # 11 was admitted to the facility on February 25, 2015, and was still an active client at the time of inspection. The facility failed to document a complete client record which included a record of services provided in client record # 11.
Client # 12 was admitted to the facility on January 25, 2015, and was still an active client at the time of inspection. The facility failed to document a complete client record which included a record of services provided in client record # 12.
Client # 13 was admitted to the facility on September 22, 2014 and discharged on January 29, 2015. The facility failed to document a complete client record for client # 13 which included a record of services provided and a case consultation note.
Client # 14 was admitted to the facility on August 13, 2014 and discharged on January 2, 2015. The facility failed to document a complete client record for client # 14 which included a case consultation note.
Client # 15 was admitted to the facility on August 19, 2014 and discharged on January 16, 2015. The facility failed to document a complete client record for client # 15 which included a record of services provided.
Client # 16 was admitted to the facility on October 17, 2014 and discharged on February 9, 2015. The facility failed to document a complete client record for client # 16 which included a case consultation note.
Client # 17 was admitted to the facility on October 9, 2014 and discharged on February 12, 2015. The facility failed to document a complete client record for client # 17 which included a record of services provided and a case consultation note.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will meet with Clinical and Administrative Staff of 6/19/15 to review the clinical documentation and filing system which requires that a Record of Services provided be included in all clinical charts as outlined in the Policy and Procedure Manual (policy # 709.53 a 3). The Administrator who is filing any documentation will be accountable to complete the Record of Service to correspond with the document that is being filed. Clinical Supervisor will monitor during staff supervision. Division Director will monitor for compliance during random chart audits quarterly (at minimum). |