INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 30 through December 1, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia DRC Inc. 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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709.28(c)(2) 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:
(2) Specific information disclosed.
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Observations
Based on the review of client records, the facility failed to document the specific client information to be disclosed on a release of information form in two of four client records.
The findings include:
On December 1, 2011, consent to release information forms were reviewed in four client records, specifically records # 1, 2, 3 and 4. The facility did not document the specific information to be disclosed to the " Emergency Contact " on the release of information forms in client records # 1, and 4.
Client # 1 was admitted on 8/1/11. The release of information form signed by client # 1 on 8/1/11 did not include the specific information to be disclosed to the " Emergency Contact " .
Client # 4 was admitted on 7/26/11. The release of information form signed by client # 2 on 7/26/11 did not include the specific information to be disclosed to the " Emergency Contact " .
The findings were confirmed by the facility director on December 1, 2011.
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Plan of Correction
The Outpatient Program will obtain an informed and voluntary consent from the client for the disclosure of specific information disclosed in the chart.
On January 13, 2012 a record-keeping training will be facilitated to review the Confidentiality Request to Release Information Form and DOH Policy 709.28(c)(2).
All Consent to Release Information Forms will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings and to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible:
Deputy Division Director
Outpatient Program Director
Outpatient Program Clinical Supervisor
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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 that included an assessment of the client ' s assets/strengths, support systems, coping mechanisms, negative factors, and/or attitude toward treatment in four of four records reviewed.
The findings include:
On December 1, 2011, psychosocial evaluations in four client records were reviewed, specifically records # 1, 2, 3 and 4. The facility failed to document a psychosocial evaluation that included an assessment of the client's assets/strengths, support systems, coping mechanisms, negative factors, and/or attitude toward treatment in client records # 1, 2, 3 and 4.
Client # 1 was admitted on 8/1/11. The psychosocial evaluation in client # 1 ' s record dated 8/22/11 did not include an assessment of the client ' s coping mechanisms, negative factors, and conclusions regarding the client ' s attitude toward and ability to participate in the treatment process.
Client # 2 was admitted on 8/5/11. The psychosocial evaluation in client # 2 ' s record dated 8/16/11 did not include an assessment of the client ' s assets/strengths, support systems, negative factors, and conclusions regarding the client ' s attitude toward and ability to participate in the treatment process.
Client # 3 was admitted on 8/5/11. The psychosocial evaluation in client # 3 ' s record dated 8/16/11 did not include an assessment of the client ' s, support systems, coming mechanisms, negative factors, and conclusions regarding the client ' s attitude toward and ability to participate in the treatment process.
Client # 4 was admitted on 7/26/11. The psychosocial evaluation in client # 4 ' s record dated 8/30/11 did not include an assessment of the client ' s assets/strengths, coping mechanisms, negative factors, and conclusions regarding the client ' s attitude toward and ability to participate in the treatment process.
The findings were confirmed by the facility director on December 1, 2011.
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Plan of Correction
The Outpatient Program Counselors will start to document psychosocial evaluations based on their evaluation of the client's support systems, assets/strengths, and negative factors as outlined in DOH Policy 709.51 (b) (6).
On January 13, 2012 a record-keeping training to include how to complete the Psychosocial Evaluation per DOH Policy 709.51 (b) (6)
All Psychosocial Evaluations will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings and to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible:
Deputy Division Director
Outpatient Program Director
Outpatient Clinical Supervisor
Timeframe for Completion:
February 29, 2012
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709.94(b) LICENSURE Project management services
709.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on a physical plant inspection, the facility failed to display the hours of operation conspicuously to the general public.
The findings include:
An inspection of the facility ' s physical plant was conducted on November 29, 2011 between approximately 11:30 AM and 12:30 PM. At the time of inspection, the facility ' s hours of operation were not displayed to the public.
The findings were confirmed by the facility director on November 29, 2011.
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Plan of Correction
On November 29, 2011 during the DOH Outpatient Program facility inspection the hours of project operation was posted and displayed conspicuously to the general public on the front door.
During the January 6, 2012 staff meeting, we will review DOH Policy 709.94(b) Project Management Services.
The Program Director will monitor the posting of hours of operation daily to ensure compliance. The posting of the hours of project operation will be revised if there are any changes in the Outpatient Program Hours of Operation.
Persons Responsible:
Deputy Division Director
Outpatient Program Director
Outpatient Program Clinical Supervisor
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709.94(c) LICENSURE Project management services
709.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based on a physical plant inspection, the facility failed to display a telephone number conspicuously to the general public for emergency purposes.
The findings include:
An inspection of the facility ' s physical plant was conducted on November 29, 2011 between approximately 11:30 AM and 12:30 PM. At the time of inspection, a telephone number for emergency purposes was not displayed to the public.
The findings were confirmed by the facility director on November 29, 2011.
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Plan of Correction
On November 29, 2011 during the DOH Outpatient Program facility inspection the Outpatient Program and Emergency Contact Phone Number was posted and displayed conspicuously to the general public on the front door.
During the January 6, 2012 staff meeting, we will review DOH Policy 709.94(c) Project Management Services.
The Program Director will monitor the posting of the Outpatient Program and Emergency Contact Phone Number daily. The posting will be revised if there are any changes in the Outpatient Program and Emergency Contact Phone Numbers.
Persons Responsible:
Deputy Division Director
Outpatient Program Director
Outpatient Program Clinical Supervisor
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