INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 27-30, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia DRC 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 and a plan of correction is due on December 2, 2008.
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Plan of Correction
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709.22(e)(2) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(2) A financial statement of income and expenses.
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Observations
Based on a review of the facility ' s 2007-2008 Annual Report and an interview with the facility director on October 28, 2008, the facility failed to document a complete report to include a financial statement of income and expenses for the fiscal year of 2007-2008.
Findings:
The facility did not include a financial statement of income and expenses in their 2007-2008 Annual Report. The facility documented a financial statement of income and expenses in a separate section of their policy and procedures manual but not in the actual Annual Report.
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Plan of Correction
The Division Director under the supervision of the Executive Director will ensure that the agency's actual Annual Report contains a financial statement of income and expenses within the original Annual Report as outlined in the standard.
Persons Responsible: Division Director
Timeframe for Completion: December 15, 2008
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709.22(e)(3) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(3) A statement disclosing the names of officers, directors and principal shareholders, where applicable.
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Observations
Based on a review of the facility ' s 2007-2008 Annual Report and an interview with the facility director on October 28, 2008, the facility failed to document a complete report to include a statement disclosing the names of officers, directors and principal shareholders.
Findings:
The facility did not include a statement disclosing the names of officers, directors and principal shareholders in their 2007-2008 Annual Report. The facility documented the names of officers, directors and principal shareholders in a separate section of their policy and procedures manual but not in the actual Annual Report.
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Plan of Correction
The Division Director under the supervision of the Executive Director will ensure that the agency's actual Annual Report documents the names of officers, directors, and principal shareholders within the original Annual Report as outlined in the standard.
Persons Responsible: Division Director
Timeframe for Completion: December 15, 2008
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709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based on an inspection of the facility ' s physical plant and an interview with the outpatient program director on October 28, 2008, the facility failed to secure all client records within locked storage containers.
Findings:
The facility did not secure all client records in locked storage containers. Closed client records dating back to July 2007 were stored in boxes located in the outpatient program director ' s office.
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Plan of Correction
The Division Director and Program Director will be responsible for ensuring that all current and future clients records are secured within locked storage containers.
Persons Responsible: Division Director, Program Director
Timeframe for Completion: November 14, 2008
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709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
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Observations
Based on a review of ten client records and administrative documentation on October 30, 2008, the facility failed to demonstrate efforts towards informing clients of the complete list of client rights in seven of seven records where required.
Findings:
The facility failed to document a complete list of client rights in the client handbook or the client signoff form of rights in client records # 1, 2, 3, 4, 5, 6, and 11.
The client handbook did not include:
(1)The project director may temporarily remove portions of the records prior to the inspection by the client if he/she determines that the information may be detrimental if presented to the client.
(2)The client shall have the right to appeal a decision limiting access to his records to the project director.
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Plan of Correction
The Division Director will review and update the complete list of client rights in the client handbook and/or sign-off sheet that includes the statement(s): (1) The Project Director may temporarily remove portions of the records prior to inspection by the client if he/she determines that the information may be detrimental if presented to the client; (2) The client shall have the right to appeal a decision limiting access to his/her records to the project director.
Persons Responsible: Division Director
Timeframe for Completion: December 15, 2008
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709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of twelve client records on October 30, 2008, the facility failed to document psychosocial evaluations with the counselor's evaluation of the client's eight of eight client records where required.
Findings:
The facility did not document complete psychosocial evaluations with the counselor's evaluation of the client's support systems, assets/strengths and negative factors in client records #1, 2, 3, 4, 5, 6, 7 and 11.
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Plan of Correction
A record-keeping training to include Psychosocial Evaluation will be facilitated to train and re-train clinical staff in documenting elements of the psychosocial evaluation providing the counselor's evaluation of the client's support systems, assets/strengths, and negative factors.
All psychosocial documentation will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings and monitored for three (3) months to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible: Executive Director, Division Director
Timeframe for Completion: January 30, 2008
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709.92(a)(1) 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of twelve client records on October 30, 2008, the facility failed to document the treatment plan goals in terms of measurable criteria in six of eight client records where required.
Findings:
The facility did not document treatment plans with goal that were stated in measurable criteria in client records #3, 4, 5, 6, 7 and 11.
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Plan of Correction
A revision of the treatment plan has been completed to reflect DOH Treatment Planning Standards. A record-keeping training to include the treatment plan will be facilitated to ensure that all staff are trained and re-trained in treatment plans with goals that are stated in measurable criteria, completed according to established timeframes, and placed in the client records as required by the standard.
All treatment plan documentation and compliance timeframes will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings and monitored for three (3) months to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible: Executive Director, Division Director
Timeframe for Completion: January 30, 2008
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709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of twelve client records on October 30, 2008, the facility failed to document the proposed support services on the treatment plans in three of eight client records where required.
Findings:
The facility did not document the proposed type(s) of support service(s) on the treatment plans in client records #3, 6 and 11.
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Plan of Correction
A revision of the treatment plan has been completed to reflect DOH Treatment Planning Standards. A record-keeping training to include a review of treatment plan standards will be facilitated to ensure that all staff document proposed type(s) of support service(s) on the treatment plans in client records.
All treatment plan update documentation and compliance timeframes will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings and monitored for three (3) months to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible: Executive Director, Division Director
Timeframe for Completion: January 30, 2008
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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 twelve client records on October 30, 2008, the facility failed to document an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan on the treatment plan update in seven of seven client records where due.
Findings:
The facility did not document an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan on the treatment plan update in client records #1, 2, 3, 4, 5, 6 and 11.
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Plan of Correction
A revision of the treatment plan has been completed to reflect DOH Treatment Planning Standards. A record-keeping training to include a review of the treatment planning systems will be facilitated to ensure that all staff document an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan as required by the Division of Drug and Alcohol Licensure.
All treatment plan update documentation and compliance timeframes will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings and monitored for three (3) months to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible: Program Director
Timeframe for Completion: January 30, 2008
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