INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 19, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Erie, Inc. - Community House 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 December 18, 2009.
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Plan of Correction
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709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records and facility policy and procedure, the facility failed to document medical histories by the third treatment session in one of two client records.
The findings include:
Four outpatient client records were reviewed on November 19, 2009. Facility policy and procedure state that medical histories are to be completed by the third treatment session. Medical histories were due in two client records. The facility did not document medical histories by the third treatment session in client record # 5.
Client # 5 was admitted on July 7, 2009. The medical history was due by July 22, 2009. The medical history was completed on August 28, 2009.
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Plan of Correction
A new counselor was hired on 8/31/09 and completed her 80 hours of training on 9/11/09. Effective immediately, medical histories will be completed within required time frames. This will be monitored by the Program Supervisor, Division Director and reviewed in the monthly UR/QI meetings. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of client records, the facility failed to document a drug and alcohol history by the third treatment session in one of two client records.
The findings include:
Four outpatient client records were reviewed on November 19, 2009. Facility policy and procedure states that drug and alcohol histories are to be completed by the third treatment session. Drug and alcohol histories were due in two client records. The facility did not document a drug and alcohol history by the third treatment session in client record # 5.
Client # 5 was admitted on July 7, 2009. The drug and alcohol history was due by July 22, 2009. The drug and alcohol history was completed on August 28, 2009.
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Plan of Correction
A new counselor was hired on 8/31/09 and completed her 80 hours of training on 9/11/09. Effective immediately, drug and alcohol histories will be completed within required time frames. This will be monitored by the Program Supervisor, Division Director and reviewed in the monthly UR/QI meetings. |
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 by the third treatment session in one of two client records.
The findings include:
Four outpatient client records were reviewed on November 19, 2009. Facility policy and procedure state that personal histories are to be completed by the third treatment session. Personal histories were due in two client records. The facility did not document a personal history by the third treatment session in client record # 5.
Client # 5 was admitted on July 7, 2009. The personal history was due by July 22, 2009. The personal history was completed on August 28, 2009.
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Plan of Correction
A new counselor was hired on 8/31/09 and completed her 80 hours of training on 9/11/09. Effective immediately, personal histories will be completed within required time frames. This will be monitored by the Program Supervisor, Division Director and reviewed in the monthly UR/QI meetings. |
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 by the third treatment session in one of two client records.
The findings include:
Four outpatient client records were reviewed on November 19, 2009. Facility policy and procedure state that psychosocial evaluations are to be completed by the third treatment session. Psychosocial evaluations were due in two client records. The facility did not document a psychosocial evaluation by the third treatment session in client record # 5.
Client # 5 was admitted on July 7, 2009. The psychosocial evaluation was due by July 22, 2009. The psychosocial evaluation was completed on August 28, 2009, and updated on September 11, 2009.
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Plan of Correction
A new counselor was hired on 8/31/09 and completed her 80 hours of training on 9/11/09. Effective immediately, psychosocial evaluations will be completed within required time frames. This will be monitored by the Program Supervisor, Division Director and reviewed in the monthly UR/QI meetings. |
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 client records, the facility failed to document a treatment plan update within the 60 day time frame in one of one client record.
The findings include:
Four outpatient client records were reviewed on November 19, 2009. Facility policy and procedure states that treatment and rehabilitation plans shall be reviewed and updated at least every 60 days. Treatment plan updates were due in one client record. The facility did not document a treatment plan update within the 60 day time frame in client record # 5.
Client # 5 was admitted on July 7, 2009. The treatment plan was done on August 7, 2009, and the treatment plan update was due by October 7, 2009. The treatment plan update was completed on October 23, 2009.
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Plan of Correction
A new counselor was hired on 8/31/09 and completed her 80 hours of training on 9/11/09. Effective immediately, treatment plans and updates will be completed within required time frames. This will be monitored by the Program Supervisor, Division Director and reviewed in the monthly UR/QI meetings. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document a case consultation within the 60 day time frame in one of two client records.
The findings include:
Four outpatient client records were reviewed on November 19, 2009. Facility policy and procedure state that case consultations shall be completed every 60 days. Case consultations were due in two client records. The facility did not document a case consultations within the 60 day time frame in client record # 5.
Client # 5 was admitted on July 7, 2009. The case consultations were due by September 7, 2009 and November 7, 2009. One case consultation was completed on October 29, 2009.
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Plan of Correction
A new counselor was hired on 8/31/09 and completed her 80 hours of training on 9/11/09. Effective immediately, case consultations will be completed within required time frames. This will be monitored by the Program Supervisor, Division Director and reviewed in the monthly UR/QI meetings.
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709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document a discharge summary within one week of discharge in one of two client records.
The findings include:
Four outpatient client records were reviewed on November 19, 2009. Facility policy and procedure states that discharge summaries are due within one week of discharge. Discharge summaries were required in two client records. The facility did not document a discharge summary within one week of discharge in client record # 6.
Client # 6 was admitted on January 9, 2009 and was discharged on April 2, 2009. The discharge summary was due by April 9, 2009. The discharge summary was completed on May 6, 2009.
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Plan of Correction
A new counselor was hired on 8/31/09 and completed her 80 hours of training on 9/11/09. Effective immediately, discharge summaries will be completed within required time frames. This will be monitored by the Program Supervisor, Division Director and reviewed in the monthly UR/QI meetings.
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