INITIAL COMMENTS
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This report is a result of an on-site licensure inspection conducted on October 8 - 9, 2015 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.
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Plan of Correction
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709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records, the facility failed to document a personal history in two of nine records reviewed.
The findings include:
Nine client records were reviewed on May 13, 2015, for documentation of a personal history. The facility failed to document a personal history in client records, # 5 and 6.
Client # 5 was admitted to the facility on July 17, 2015. The facility failed to document a personal history for client # 5 as of the date of the licensing inspection.
Client # 6 was admitted to the facility on May 25, 2015 and discharged on July 28, 2015. The facility failed to document a personal history during client # 6's duration of treatment.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Addiction Severity Index (ASI) is completed during the intake process. The ASI is used for the assessment of substance use-related problems. The ASI will get a better understanding of the participant?s treatment needs and outcomes. Instead of just considering the participant?s substance use, the ASI as aims it?s spotlight on the individual?s medical, employment, legal, family, social and psychiatric history. This wide angle view is designed to assist in getting a better understanding not just of the substance use, it also other problems that affect the participant and his/her recovery.
The Intake Supervisor will review intake documentation daily to ensure that the ASI has been completed.
The Clinical Supervisor will review intake documentation to ensure that the ASI has been completed when doing monthly open chart audits.
Client #5 ASI was completed during Intake on 7/17/15. Confirmation of it being in the clinical record was made by the Program Director.
Client #6 ASI was completed during Intake on 5/25/15. Confirmation of it being in the clinical record was made by the Program Director.
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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 client records, the facility failed to document a psychosocial evaluation in two of nine records reviewed.
The findings include:
Nine client records were reviewed on May 13, 2015, for documentation of a psychosocial evaluation. The facility failed to document a psychosocial evaluation in client records, # 3 and 7.
Client # 3 was admitted to the facility on July 7, 2015. The facility failed to document a psychosocial evaluation as of the date of the licensing inspection.
Client # 7 was admitted to the facility on June 12, 2015 and discharged on September 10, 2015. The facility failed to document a psychosocial evaluation during client # 7's duration of treatment.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The client will meet with Primary Counselor for individual counseling sessions once weekly. The primary counselor will focus on establishing rapport with the client while discussing the D&A and Med/Psych histories and the data collected during the intake. The counselor will begin gathering data to complete the Psychosocial History. The counselor is expected to fully complete the family history, legal history, employment/vocational history, educational history, sexual history, abuse history, recreational/leisure time history, military history and treatment receptivity within three individual sessions. Upon completion of the Psychosocial History the counselor will write a psychosocial assessment and submit to Clinical Supervisor for review prior to the next individual session.
The Program Director will monitor due dates for psychosocial weekly. Pending psychosocial will be reviewed at weekly clinical staff meetings.
The Program Director reviewed Client #3 chart and bio-psychosocial was completed on 01/30/15. Psychosocial was confirmed as being in the client record by Record Room clerk on 11/17/15.
The Program Director reviewed Client #7 chart and bio-psychosocial was completed on 6/12/15. Psychosocial was confirmed as being in the client record by Record Room clerk on 11/17/15.
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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
Based on a review of client records, the facility failed to document a complete client record in nine out of ten client records reviewed.
The findings include:
Ten client records were reviewed on October 8 - 9, 2015. The facility failed to document a complete client record that included a record of services provided, progress notes, case consultation notes, aftercare plans, discharge summary in client's records, #1, 2, 3, 4, 6, 7, 8, 9.
Client # 1 was admitted to the facility on June 24, 2015. The facility failed to document a complete record of services provided to client # 1. The facility documented sessions on the record of service, but failed to provide DAP progress notes for those services rendered; similarly the facility provided DAP progress notes but failed to document that service on the record of the service log.
Client # 2 was admitted to the facility on June 30, 2015. The facility failed to document a complete record of services provided to client # 2. The facility documented sessions on the record of service, but failed to provide DAP progress notes for those services rendered; similarly the facility provided DAP progress notes but failed to document that service on the record of the service log.
Client # 3 was admitted to the facility on July 7, 2015. The facility failed to document a complete record of services provided to client # 3. The facility documented sessions on the record of service, but failed to provide DAP progress notes for those services rendered; similarly the facility provided DAP progress notes but failed to document that service on the record of the service log.
Client # 4 was admitted to the facility on July 3, 2015. The facility failed to document a complete record of services provided to client # 4. The facility documented sessions on the record of service, but failed to provide DAP progress notes for those services rendered; similarly the facility provided DAP progress notes but failed to document that service on the record of the service log.
Client # 5 was admitted to the facility on July 17, 2015. The facility failed to document a complete record of services provided to client # 5. The facility provided DAP progress notes that were not documented on the record of service log,
Client # 6 was admitted to the facility on May 25, 2015 and discharged on July 28, 2015. The facility failed to document a discharge summary and complete record of services provided to client # 6. The facility documented sessions on the record of service, but failed to provide DAP progress notes for those services rendered; similarly the facility provided DAP progress notes but failed to document that service on the record of the service log.
Client # 7 was admitted to the facility on June 12, 2015 and discharged on September 10, 2015. The facility failed to document a discharge summary and complete record of services provided to client # 7. The facility documented sessions on the record of service, but failed to provide DAP progress notes for those services rendered; similarly the facility provided DAP progress notes but failed to document that service on the record of the service log.
Client # 8 was admitted to the facility on May 21, 2015. The facility failed to document an aftercare plan, discharge summary and complete record of services provided to client # 8. The facility documented sessions on the record of service, but failed to provide DAP progress notes for those services rendered; similarly the facility provided DAP progress notes but failed to document that service on the record of the service log.
Client # 9 was admitted to the facility on January 27, 2015 and discharged on June 10, 2015. The facility failed to document a case consultation, aftercare plan and discharge summary at the time of the licensing inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All services rendered to a client shall be documented on the Outpatient Service Record Form, which is maintained in the client record. The Counselor or staff person providing the service shall record the date a service is provided and complete the group or individual note.
The Clinical Supervisor will review the Outpatient Service Record and supporting documentation when doing monthly open chart audits to ensure documentation is being completed and filed in the client record.
The Clinical Supervisor will review the clinical charts of client #1, client #2, client #3, client #4, client #6, client 7, client #8 and client #9 to ensure that all group and individual progress notes are present.
The Clinical Supervisor will utilize Outpatient Service Record to identify the clinician responsible for documenting the clinical session.
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709.17(a)(1) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(1) Failure to comply with a directive issued by the Department.
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Observations
Based on a review of administrative documentation, the facility failed to comply with the directive issued by the Department requiring the facility to develop and implement policies and procedures for the reporting of unusual incidents.
The findings include:
As per the directive within Chapter 709 Subchapter C enacted on 10/18/2014, the facility was required to develop and implement policies and procedures for the reporting of unusual incidents. The facility's administrative records were reviewed for documentation of policies and procedures for the reporting of unusual incidents on October 6, 2015. As of the date of the inspection, the facility has not developed policies and procedures for the reporting of unusual incidents.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facility has updated the current unusual incident policy to include all DDAP specifications. The unusual incident policy update was completed during the week of the DDAP audit (10/09/15. |