INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 22, 2013 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Gaudenzia (Coatesville) 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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709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on the review of client records, the facility failed to document the type and frequency of service to be offered to each client on each treatment plan.
The findings included:
During the onsite inspection conducted on May 22,2013, nine client records were reviewed. Each record was required to document the type and frequency of treatment to be offered to each client on the master treatment plan. Two of nine records failed to document the frequency of service to be offered to the client.
Client # 4 was admitted on October 26, 2012 and discharged on April 11, 2013. The master treatment plan was formulated on February 8, 2013 . There was no frequency documented on the treatment plan.
Client # 6 was admitted on April 6, 2013 and discharged on February 1, 2013. The master treatment plan was formulated on April 20, 2013. There were no frequency documented on the comprehensive treatment plan.
This was confirmed by the Facility Director on May 22, 2013.
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Plan of Correction
Each treatment plan will document the frequency and type of services for each client. This will be monitored the clinical supervisor and program director via admission report and weekly auditing of the charts. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document a treatment plan update in three of three client records.
The findings include:
Nine client records were reviewed on May 22, 2013. Two of Nine client records were required to have a treatment plan update . Per the facility policy, treatment plan updates are required to be completed within 60 days of the outpatient comprehensive treatment plan and 30 days on the IOP treatment plan. The facility failed to document a treatment plan update in client records # 5, 7, and 9.
Record #5 - The client was admitted on October 24, 2012. The comprehensive treatment plan was completed on November 2, 2012. A IOP treatment plan update was completed on February 23, 2013, March 23, 2013 and April 23, 2013. An update was due by April 23, 2013. As of May 22, 2013, an IOP treatment plan update was not completed.
Record #7 - The client was admitted on June 13, 2012 and discharged on February 12, 2013. The comprehensive treatment plan was completed on July 3, 2012. A treatment plan update was due and completed on August 11, 2012. An update was due according to the IOP treatment plan on September 8, 2012 and completed on October 23, 2012. An update was due on November 23, 2012 but not completed until January 18, 2013. It was documented on the updates that the plans were late in completion.
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Plan of Correction
Each clinician will utilize an excel spreadsheet that will give the timelines for each treatment due date, whether the client is in IOP or OP. This will be monitored in weekly audits by clinical supervisor and program director. |
709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
Based on a review of client records, the facility failed to document a physician signature on the individual treatment plans for medical assistance clients within the timeframe's established by the Office of Medical Assistance in two of two client records.
The findings included:
Nine client records were reviewed on May 22, 2013. Two of the two client records are required to have a physician signature on the individual treatment plans. The individual treatment plans contained in client records #6 and #8 did not contain a physician signature established by the Office of Medical Assistance.
Client #6 was admitted on April 6, 2012 and discharged February 1, 2013. The individual treatment and rehabilitation plan was developed on April 20, 2012 and did not include a physician signature.
Client #8 was admitted to outpatient treatment on July 19, 2012 and discharged on February 24, 2013. The individual treatment and rehabilitation plan was developed on August 9, 2012 and did not include a physician signature.
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Plan of Correction
Each treatment plan will be signed by a licensed physician. Each clinician will be responsible for identifying the treatment plans that need to be signed. This will be monitored by clinical supervisor and program director in weekly chart audits and supervision. |