INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 15 -16, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Ellen O'Brien Gaiser Addiction Center 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 November 14, 2007.
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Plan of Correction
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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 on a client record review on 10-16-07, the facility failed to protect confidentiality by documenting the full names of other clients on the group treatment notes in client records. This occurred in client records # 1, 2 and 3.
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Plan of Correction
On 10/23/07 The Exeucutive Director and Clinical Director performed a confidentiality regulatory overview with all Gasier Stall including the importance of NEVER including client last names on group treatment notes or any other material that is placed in multiple client charts. This will be monitored regularly going forward by the Executive Director, Clinical Director and the Clinical Leads of each program. |
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 the client records on 10-16-07, the facility failed to include revised goals and objectives on the treatment plan update. This occurred in two of two client records, # 1 and 2.
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Plan of Correction
On 10/23/07 the Clinical Director conducted a formal clinical training on the correct manner in which to include revised goals and objectives on the treatment plan update of each client. Going forward the clinical director and the clinical leads of each program will regularly review the clinicains' treatment plan updates for accuracy going forward. |