INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 20, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Division of Accountability and Program Improvement. Based on the findings of the on-site inspection, Gaudenzia Erie Inc. Community 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.
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Plan of Correction
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709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
The facility failed to document an informed and voluntary consent from the client prior to the disclosure of information to the funding entity in one of nine client records reviewed on September 20, 2018.
Client # 6 was admitted April 17, 2018 and discharged July 31, 2018.
The findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Program Director will review all required intake documentation with clinical and administrative staff, specifically informed and voluntary consent forms. This review will occur by 11/10/2018.
Program Director will complete monthly chart audits, beginning in November 2018, to ensure informed and voluntary consent forms are completed. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. 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:
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Observations
The facility failed to document an individual treatment plan that included the type and frequency of treatment and rehabilitation services in two of five residential client records reviewed on September 20, 2018.
Client # 7 was admitted May 14, 2018 and discharged August 9, 2018. The individual treatment plan was completed on May 23, 2018.
Client # 8 was admitted May 9, 2018 and discharged July 30, 2018. The individual treatment plan was completed on May 24, 2018.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will ensure type and frequency of treatment provided is included in all treatment plans via monthly chart audits beginning November 2018.
The agency's electronic health records has modified the template to document this information. |
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
The facility failed to document a treatment plan update at least every sixty days in two of two outpatient client records reviewed on September 20, 2018.
No treatment plan updates were documented in the following client records.
Client # 5 was admitted April 5, 2018 and discharged on July 30, 2018. The individual treatment plan was completed May 17, 2018.
Client # 6 was admitted April 17, 2018 and discharged on July 31, 2018. The individual treatment plan was completed May 18, 2018.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the 2017 annual inspection.
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Plan of Correction
Program Director will train staff regarding treatment planning according to licensing standard by 11/5/18. Staff will also be trained to document any missed appointments and attendance issues that contribute to late updates in a case note by 11/5/18.
Program Director will monitor compliance with treatment plan standards via chart audit beginning November 2018.
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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
The facility failed to document a complete client record including progress notes and follow-up information in four of four outpatient client records reviewed on September 20, 2018.
Client # 2 was admitted February 16, 2018 and discharged July 26, 2018.
Progress notes were not documented for the following individual sessions: February 16, 2018, June 6, 2018 and July 6, 2018.
Progress notes were not documented for the following group sessions: March 21, 2018, March 28, 2018 and April 10, 2018.
Client # 4 was admitted July 11, 2018.
Progress notes were not documented for the following individual sessions: July 11 and July 17, 2018.
Progress notes were not documented for the following group sessions: July 17 and July 24, 2018.
Client # 5 was admitted April 5, 2018 and discharged July 30, 2018.
Progress notes were not documented for the following individual sessions: April 5, 2018. Progress notes were not documented for the following group sessions: May 8, 2018, May 22, 2018 and June 26, 2018.
Client # 6 was admitted April 17, 2018 and discharged July 31, 2018.
Progress notes were not documented for the following individual sessions: May 11, 2018, June 1, 2018, June 22, 2018, June 29, 2018 and July 6, 2018.
Progress notes were not documented for the following group sessions: May 11, 2018, May 18, 2018 and June 1, 2018.
No follow-up information was documented.
Client # 5 was admitted April 5, 2018 and discharged July 30, 2018.
Client # 6 was admitted April 17, 2018 and discharged July 31, 2018.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will train all staff in regards to progress notes and follow up information as per licensing requirements by 11/5/2018.
Program Director will monitor compliance with above licensing mandates and technical issues via monthly chart audit beginning November 2018. |