INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 17 and 18, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Erie, Inc. - Daniel Snow House - 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 and a plan of correction is due on January 31, 2008.
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Plan of Correction
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709.51(b)(3)(iii) LICENSURE Personal History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records the facility failed to document a complete personal history in three out of three client records reviewed, specifically client records # 1, 2 and 3. Personal histories did not include pertinent personal data on employment, recreational, and family histories.
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Plan of Correction
Program Supervisor will train staff on personal histories and the need to have all areas addressed fully which include employment, recreational and family histories. He will monitor compliance monthly during the agencie's Quality Improvement process. |
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
Based on review of client records, the facility failed to document complete progress notes in three out of three client records reviewed, specifically client records # 1, 2 and 3. The group progress notes did not include a data section that was individualized by the counselor for each group participant, that included observation and information about the client. The assessment did not include the counselor's analysis of and conclusions regarding the client's interactions during the group sessions. The group notes lacked sufficient detail to determine whether the group notes described clinical/therapeutic sessions or educational sessions.
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Plan of Correction
Division Director will train all clinical staff on the appropriate way to complete clinical group notes. This clinical staff training will be held on or before 2/29/08. Program Directors and Supervisors will monitor compliance during the agency's monthly Quality Improvement program. |