INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 26, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia West Shore, 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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709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
On May 26, 2016, a review of 2015 unusual incidents was conducted. The facility failed to provide a written report within 3 business days to the Department of an overdose death dated May 4, 2015, as of the date of the inspection.
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Plan of Correction
Effective immediately, all unusual incidents will be recorded via the required Department form and will be submitted to the Program Director for review within 24hours of the incident. The Unusual Incident Report Form will be signed off by the Program Director and forwarded to the Department of Drug and Alcohol Programs within 3 business days. All fax and/or read receipts will be attached to the report and kept on file for future reference or review.
A supervisory session will occur with the Program Supervisor regarding the above by 6/16/16.
The Program Director will maintain oversight of the above.
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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 ten client records on May 26, 2016, the facility failed to develop an individual treatment and rehabilitation plan in five client records, #1, 2, 4, 5 and 8. Additionally the facility failed to document that the individual treatment and rehabilitation plans were developed with their counselor in five client records, #3, 6, 7, 9 and 10.
Client #1 was admitted to treatment on July 16, 2015 and was discharged on 11/30/2015. There was no plan found in the client record.
Client #2 was admitted to treatment on October 9, 2015 and discharged December 28, 2015. There was no plan found in the client record.
Client #3 was admitted to treatment on July 8, 2015 and discharged January 22, 2016. The plan was developed and signed by the counselor on August 8th, but was not signed by the client until October 21, 2015.
Client #4 was admitted to treatment on December 14, 2015 and discharged March 23, 2016. There was no plan found in the client record.
Client #5 was admitted to treatment on September 25, 2015 and discharged February 2, 2016. There was no plan found in the client record.
Client #6 was admitted to treatment on January 6, 2016 and discharged April 15, 2016. The plan was developed February 6th, signed by the counselor on February 17th, but said that the client signed it on February 16, 2016.
Client #7 was admitted to treatment on December 21, 2015 and is still an active client. The plan was developed and signed by the counselor on February 19th and signed by the client on February 24, 2016.
Client #8 was admitted to treatment on February 9, 2016 and is still an active client. There was no plan found in the client record.
Client #9 was admitted to treatment on November 12, 2015 and is still an active client. The plan was developed and signed by the counselor on January 12, 2015 and signed by the client on February 22, 2016.
Client #10 was admitted to treatment on July 28, 2015 and is still an active client. The plan was developed and signed by the counselor on August 27, 2015 and signed by the client on September 22, 2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, counselors will complete a preliminary/initial treatment plan, according to Gaudenzia's Policy & Procedures Manual, during the first outpatient or intensive outpatient contact session (not at the assessment session).
Within 30 days of the preliminary/initial treatment plan, a comprehensive treatment plan will be completed with the individual and signed by the client during that session. Treatment plan updates will occur every 30 days thereafter for intensive outpatient and every 60 days thereafter for outpatient.
To ensure compliance, the Program Supervisor will review for presence of the initial/preliminary/comprehensive and updated treatment plans, dates and signatures and will continue to monitor through monthly chart audits.
The Program Director will be responsible for oversight.
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709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records on May 26, 2016, the facility failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plan in records #3, 4, 7, 8, 9 and 10.
Client #3's treatment plan dated August 8, 2015 and updates of September 8th, October 8th, and November 8, 2015 stated that the client was to receive individual counseling sessions once per week. Client was not seen in September 2016, twice in October 2016, none in November 2016, three times in December 2016. Client was discharged January 22, 2016.
Client #4's treatment plan dated December 14, 2015 stated that the client was to receive individual counseling sessions once per week. Client #4 only received individual counseling sessions on 12/14/15, 2/17/16 and 3/1/16 prior to being discharged March 23, 2016.
Client #7's treatment plan of February 19, 2016 and update of April 19, 2016 stated that the client was to receive individual counseling sessions once per week. Client #7 received individual sessions on 2/24/16, none for March, and one for the month of April 4/18/16. Client is an active client.
Client #8's treatment plan of February 9, 2016 stated that the client was to receive individual counseling sessions once per week. Client #8 had a physical injury between March 19th to April 19th and only received an individual session on 5/18/16. Client is an active client.
Client #9's treatment plan of January 12, 2016 and update of March 8th stated that the client was to receive individual counseling sessions once per week. Client #9 was seen 2/22/16, 3/8/16, none in April, and seen on 5/10/16 and 5/24/16. Client is an active client.
Client #10's treatment plan dated August 27, 2015 and updates stated that the client was to receive individual counseling sessions once per week. Client #10 was compliant for September. Client was only seen once in October 2016, twice in November 2016, twice in December 2016, three times in January 2016, three times in February 2016, three times in March 2016, three times in April 2016 and twice in May 2016. Client is an active client
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, counselors will reflect on the Record of Service when a client is a no show or a cancel/reschedule to reflect client involvement according to the prescribed treatment plan.
Counselors will also document on the record of service or log note any attempts to contact the client to re-engage in services when they have been absent.
Chart #7, #8, #9, #10 will be updated to reflect no show/cancel/reschedule status on the record of service. Chart #3 and #4 have been discharged.
The Program Supervisor will review compliance for Quality Improvement during monthly chart audits and will discuss in supervisory sessions, as needed.
The Program Director will be responsible for oversight of the above. |