INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 12, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Montgomery County Outpatient 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 September 25, 2008.
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Plan of Correction
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705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based upon a physical plant inspection conducted on August 12, 2008, the facility failed to ventilate two of the three bathrooms by means of an operable exhaust fan or window.
Findings:
The male and female client bathroom exhaust fans were not operable.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based upon a review of five client records on August 12, 2008, three records were reviewed for confidentiality, of those three records, the facility failed to obtain an informed an voluntary consent from the client to release information in three of three client records reviewed.
Findings:
The facility is using a "Medical Release" form which constitutes a general consent to release information. The form fails to indicate who the information will be released to in three of three client records reviewed, #1, 2 & 3.
Consents to release information in client records #1 & 2 contained forms which did not allow for the verbal revocation of the consent to release information form.
Client record #1 contained a consent to release information to an emergency contact and failed to list what would be released.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based upon a review of five client records on August 12, 2008, three were reviewed to ensure that the facility disclosed the criteria for admission, treatment, completion and discharge to the client and documented the disclosure of the form to the client. The facility failed to include a copy of a sign off form in one of three records reviewed.
Findings:
Client record #1 lacked a signed copy of the form to verify that the client had been informed of the criteria for admission, treatment, completion and discharge.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 upon a review of five client records on August 12, 2008, three were reviewed for individualized treatment plans and their completion by the third session as per facility policy. The facility failed to complete the treatment plan by the third session in one of three records reviewed and the facility failed to document support services in three of three records reviewed.
Findings:
One of three client records reviewed, #3, lacked an individualized treatment plan. The treatment plan had not been done as of 5th session. The client was admitted 4-22-08, the treatment plan was due on 7-22-08 and had not yet been completed as of the 8-7-08 individual session nor as of the date of this inspection, 8-12-08.
Client records #1 & 3 did not include possible support services on the treatment plans.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based upon a review of five client records on August 12, 2008, two records required that a follow-up be completed. The facility failed to complete the follow-up contact attempts within thirty days from the date of discharge for clients that are not referred elsewhere, in accordance with the facility policy and procedure in two of two client records where required.
Findings:
Clients records #4 & 5 were both discharged on 6/21/08. No follow up contact attempts had been documented as of the date of the inspection on August 12, 2008.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |