INITIAL COMMENTS
|
This report is a result of an on-site licensing inspection conducted on December 6-9, 2011, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Gaudenzia Erie, Inc - Corry Satellite Office 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.
|
Plan of Correction
|
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a client record review, the facility failed to complete psychosocial evaluations as stated in facility policy in two of four client records.
The findings include:
Four complete outpatient records were reviewed on December 8, 2011. All four client records were required to have a psychosocial evaluation completed by the client's fourth individual session, as per facility policy. Client records #1 and 2 did not contain psychosocial evaluations that were completed by the client's fourth individual session.
Client #1 was admitted to outpatient treatment on August 19, 2011. The client's fourth individual session was completed on September 22, 2011 and the psychosocial evaluation was due to be completed by that date. Client #1 had a psychosocial evaluation completed on December 2, 2011.
Client #2 was admitted to outpatient treatment on August 8, 2011. The client's fourth individual session was completed on September 12, 2011 and the psychosocial evaluation was due to be completed by that date. Client #2 has a psychosocial evaluation completed on September 19, 2011.
An interview with the clinical supervisor took place on December 8, 2011. The aforementioned dates of completion were confirmed.
|
Plan of Correction
Program Director of Outpatient will review/train staff on agency policies in regards to time frames of documentation of biopsychosocial evaluations, related assessments and treatment plans. Training will be completed on 1/27/12 and will be monitored by the Program Director during UR/QI process |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
|
Observations
Based on a review of client records, the facility failed to document an individual treatment and rehabilitation plan as per agency policy in three of four client records.
The findings include:
Four complete outpatient client records were reviewed on December 8, 2011. Individual treatment and rehabilitation plans were required in all four client records. Per facility policy, "The individualized treatment plan shall be completed, approved and signed by the client and by the counselor within 4 sessions." Individualized treatment and rehabilitation plans were not documented as per agency policy in client records # 1, 2 and 6.
Client #1 was admitted to outpatient treatment on August 19, 2011. The 4th session was completed on September 8, 2011 and the individualized treatment and rehabilitation plan was due to be completed by that date. The individualized treatment and rehabilitation plan was completed on November 10, 2011.
Client #2 was admitted to outpatient treatment on August 8, 2011. The 4th session was completed on September 1, 2011 and the individualized treatment and rehabilitation plan was due to be completed by that date. The individualized treatment and rehabilitation plan was completed on September 19, 2011.
Client #6 was admitted to outpatient treatment on July 12, 2011. The 4th session was completed on August 3, 2011 and the individualized treatment and rehabilitation plan was due to be completed by that date. The individualized treatment and rehabilitation plan was completed on September 1, 2011.
An interview with the clinical supervisor took place on December 8, 2011 at which time the completion dates for the individualized treatment and rehabilitation plans were confirmed.
|
Plan of Correction
Program Director of Outpatient will review/train staff on agency policies in regards to time frames of documentation of biopsychosocial evaluations, related assessments and treatment plans. Training will be completed on 1/27/12 and will be monitored by the Program Director during UR/QI process |
709.93(a)(8) 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:
(8) Case consultation notes.
|
Observations
Based on a review of client records, the facility failed to document case consultations as per facility policy in two of four client records.
The findings include:
Four complete client records were reviewed on December 8, 2011. Case consultations were required to be completed in all four client records. Per facility policy, case consultations for outpatients are to be completed in the first thirty days of treatment and then every sixty days thereafter. Case consultations were not completed as required by facility policy in client records # 1 and 2.
Client #1 was admitted to outpatient treatment on August 19, 2011. Case consultations were due to be completed by September 19 and November 19, 2011. Case consultations were completed on September 30 and December 2, 2011.
Client #2 was admitted to outpatient treatment on August 8, 2011. Case consultations were due to be completed by September 8 and November 8, 2011. One case consultation was completed on November 18, 2011.
An interview with the clinical supervisor took place on December 8, 2011 and the aforementioned information was confirmed.
|
Plan of Correction
Program Director of Outpatient will review/train staff on agency policies in regards to time frames of documentation of and treatment plans. Training will be completed on 1/27/12 and will be monitored by the Program Director during UR/QI process |
709.93(a)(10) 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:
(10) Discharge summary.
|
Observations
Based on a review of client records, the facility failed to document a discharge summary within seven days of discharge in two of four client records.
The findings include:
Four discharged outpatient client records were reviewed on December 8, 2011. A discharge summary, which is to be completed within seven days of discharge, per facility policy, was required in all four client records. The facility did not document a discharge summary within seven days of discharge in client records # 4 and 7.
Client #4 was admitted to outpatient treatment on June 23, 2011 and was discharged on September 3, 2011. A discharge summary was due to be completed by September 10, 2011. There was no discharge summary in client record #4.
Client #7 was admitted to outpatient treatment on July 21, 2011 and was discharged on October 20, 2011. A discharge summary was due to be completed by October 27, 2011. The discharge summary in client record #7 was completed on October 28, 2011.
An interview with the clinical supervisor took place on December 8, 2011 at which time the aforementioned information was confirmed.
|
Plan of Correction
Program Director of Outpatient will review/train staff on agency policies in regards to time frames of documentation of discharge summaries. Training will be completed on 1/27/12 and will be monitored by the Program Director during UR/QI process |