INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 11, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia, Inc., 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) 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:
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Observations
Based on a review of client records on May 11, 2016, the facility failed to document an individual treatment and rehabilitation plan that was developed with the client in client record #12.
Client #12 was admitted to treatment on July 8, 2015 and discharged on December 22, 2015. Client #12's individual treatment and rehabiltation plan was developed and signed by his counselor on August 20, 2015. The client did not sign the plan until September 16, 2015.
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Plan of Correction
An all staff in service training will be held on June 17, 2016 to address clinical staff on treatment management procedures specific to the treatment planning process. All staff will be directed to develop comprehensive treatment plans with the client within 30 days of admission and shall be driven by the client's self assessed SNAP goals. In cases where the client fails to show for a scheduled session within the timeframe, the timeline deficiency will be reflected on both the client record of service as well as the comprehensive treatment plan during the next attended individual session.
The Clinical Supervisor and Division Director will review treatment plans for compliancy during the CQI process monthly. Clinical staff will be monitored monthly in regular supervisory sessions as well as weekly clinical meetings.
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709.94(c) LICENSURE Project management services
709.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based on a physical plant inspection conducted on May 11, 2016 at approximately 10:00 a.m., the facility failed to display an emergency telephone number.
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Plan of Correction
On May 11, 2016 Division Director wrote Gaudenzia Middleburg's emergency phone number on the hours of operation sign posted on the main entrance door.
Division Director will monitor signs monthly to ensure visibility and compliance. |