INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 2, 2008 and June 3, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia,Inc. - People with Hope/Short-Term Program 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 July 3, 2008.
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Plan of Correction
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709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
The non-hospital treatment and rehabilitation facility failed to document physical examinations as part of the Intake and Admission process in three of eight client records reviewed.
In two of eight client records reviewed, physical examinations were not documented within seven days of admission. In one other client record the physical examination was missing.
Findings:
Client Record #5 - Admitted on September 12, 2007. Physical examination documented on October 23, 2007. The physical examination was due by September 20, 2007.
Client Record # 6 - Admitted on September 13, 2007. Physical examination documented on September 29, 2007. The physical examination was due by September 21, 2007.
Client Record # 7 - Admitted on April 22, 2008. Discharged on May 27, 2008. There was no physical examination in the client record during the June 3, 2008 review.
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Plan of Correction
Project was not in compliance with the standard due to physical examinations not documented as part of the Intake and Admission processes in three of eight client records reviewed within seven days of admission as outlined in 709.51(b)(5).
Program Director has scheduled a meeting with Nursing Manager to ensure all physical examinations are completed by either program's attending physician or the client's primary care physician within the first 48 hours of admission and documentation as well as the actual forms be placed in the client's chart by the programs' nursing staff. This process will be checked for compliance by Nursing Manager within first week of client's admission.
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709.53(a) LICENSURE Complete Client Record
709.53. 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 non-hospital treatment and rehabilitation facility failed to maintain complete client records.
One of four discharged client records reviewed on June 3, 2008 was not a complete record.
Findings:
Client record #6 - Admitted on September 13, 2007 and discharged on January 28, 2008 was missing a psychosocial evaluation, two treatment plan updates and incomplete or missing individual and group progress notes.
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Plan of Correction
Project was not in compliance with the standard due to client records reviewed indicating chart were incomplete of psychosocial evaluation, treatment plan updates, incomplete or missing individual and group progress notes as outlined in 709.53(a). This issue will be addressed with Program Director facilitating an in-service training on Clinical Record Keeping inclusive of completing concise and comprehendible psychosocial evaluation, treatment plans & updates and group and individual progress notes placing emphasis on all the noted documentation being interrelated and client focused stating clearly individualized treatment issues/therapeutic interventions. Program Director and Clinical Supervisor will conduct weekly chart audits to support training and implementation of documentation compliance standards.
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709.53(a)(12) LICENSURE Work as treatment
709.53. 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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
The non-hospital treatment and rehabilitation facility failed to include work therapy as an integral part of the treatment and rehabilitation plan.
Five of eight client records reviewed on June 3, 2008 did not have work therapy integrated into the treatment plan or treatment plan up-date
Client Record #1 - Admitted on March 4, 2008 without work therapy integrated into the treatment plan.
Client Record #2 - Admitted on February 4, 2008 without work therapy integrated into the treatment plan.
Client Record #3 - Admitted on May 15, 2008 without work therapy integrated into the treatment
plan.
Client Record #5 - Admitted on September 12, 2007 and discharged on February 29, 2008 without work therapy integrated into the treatment plan.
Client Record #6 - Admitted on September 13, 2007 and discharged on January 28, 2008 without work therapy integrated into the treatment plan.
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Plan of Correction
Project was not in compliance with the standard due to client records not having work plans integrated into the treatment plan or treatment plan updates outlined in 709.53(a)(12). This issue will be corrected with Program Director and Clinical Supervisor training the clinical staff on how to document work therapy in the initial treatment plan since clients are assigned job duties to teach and reinforce life skills & interpersonal skills development during their first week of admission into treatment. Treatment plan updates will be inclusive of clients' progress or barriers with skill development through staff and peer reinforcements through out their treatment process which will be monitored through weekly chart audits after the staff is trained on this through a topic related in-service training.
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