INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 4, 2009 through November 5, 2009 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 and a plan of correction is due on December 7, 2009.
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Plan of Correction
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705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill records, the facility failed to document the use of alternate exit routes during monthly fire drills.
The findings include:
The facility's fire drill records were reviewed on November 4, 2009. The main entrance was used during fire drills dated November 2008, April 2009, May 2009, June 2009, July 2009, August 2009, September 2009 and October 2009. No exit route was documented for fire drills dated December 2008, January 2009, February 2009 and March 2009.
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Plan of Correction
Effective December 15, 2009 Alternate routes will be utilized and documented during fire drills.
The Program Director will monitor the fire drills monthly to ensure continued compliance via the monthly Continuous Quality Improvement (CQI) process.
Persons Responsible: Outpatient Program Director
Timeframe for Completion: December 15, 2009.
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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 client records, the facility failed to document an individual treatment plan in three of six records. The facility also failed to document an individual treatment plan within the timeframe required as per the facility's policy on the management of treatment and rehabilitation services in two of six records.
The findings include:
Eight client records were reviewed on November 4, 2009 through November 5, 2009. Individual treatment plan were reviewed in six client records.
The treatment plan was due by July 3, 2009 in client record #1. A treatment plan was not documented in client record #1 as of November 5, 2009.
The treatment plan was due by June 2, 2009 in client record #3. A treatment plan was not documented in client record #3 as of November 5, 2009.
The treatment plan was due by July 17, 2009 in client record #4. A treatment plan was not documented in client record #4 as of November 5, 2009.
The treatment plan was due by June 22, 2009 in client record #2. A treatment plan was not documented in client record #2 until July 30, 2009.
The treatment plan was due by April 2, 2009 in client record #5. A treatment plan was not documented in client record #5 until April 23, 2009.
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Plan of Correction
A record-keeping training to include a review of treatment plan standards will be facilitated on January 12, 2010 to ensure that all staff document completion of Treatment Plans per DOH Policy 709.92 (a).
All treatment plan documentation and compliance timeframes will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings and monitored for three (3) months to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible: Division Director, Outpatient Program Director.
Timeframe for Completion: January 31, 2010.
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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 and an interview with the facility director, the facility failed to document a treatment plan update in three of three records.
The findings include:
Eight client records were reviewed on November 4, 2009 through November 5, 2009. A treatment plan update was required in three client records.
A treatment plan update was due to be completed by September 3, 2009 in client record #2. A treatment plan update was not documented in client record #2 as of November 5, 2009.
A treatment plan update was due to be completed by June 23, 2009 in client record #5. A treatment plan update was not documented in client record #5 as of November 5, 2009.
A treatment plan update was due to be completed by May 10, 2009 in client record #6. A treatment plan update was not documented in client record #6 as of November 5, 2009.
The failure to document treatment plan updates was addressed with the facility director. The missing documentation was not made available during the inspection.
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Plan of Correction
A record-keeping training to include a review of the treatment planning systems will be facilitated to ensure that all staff document Treatment Plan Updates as required by the Division of Drug and Alcohol Licensure.
All treatment plan update documentation and compliance timeframes will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings and monitored for three (3) months to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible: Division Director, OP Program Director
Timeframe for Completion: January 31, 2010.
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709.93(a)(2) 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:
(2) Medication records.
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Observations
Based on a review of client records and staff interviews, the facility failed to document complete medication records in two of three records.
The findings include:
There was no documentation of the dosages taken for the Prozac in client record #2. Information provide by staff interview and record documentation identified that the medication was brought into the facility by the patient at admission. The facility failed to specify the dosage and the administration of this medication in the patient and medication records.
There was no documentation of the frequency taken for Lisinopril and Zocor in client record #1. Information provide by staff interview and record documentation identified that the medication was brought into the facility by the patient at admission. The facility failed to specify the dosage and the administration of this medication in the patient and medication records.
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Plan of Correction
Gaudenzia DRC Outpatient (OP) Program does not administer, prescribe, or store medication. All medications being taken by a client will be recorded in the clients chart in the bio psychosocial indicating the name, dosage, and frequency of the medications.
All medication name, dosage, and frequency will be documented in the bio psychosocial. Chart documentation will be reviewed during monthly Continuous Quality Improvement (CQI) meetings and monitored for three (3) months to ensure compliance and completion.
Persons Responsible: Medical Department, Outpatient Program Director
Timeframe for Completion: January 31, 2010.
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709.93(a)(3) 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:
(3) Record of services provided.
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Observations
Based on a review of client records, the facility failed to document a complete record of services in two of six records.
The findings include:
Eight client records were reviewed on November 4, 2009 through November 5, 2009. A record of services was required in six client records. The record of services in client record #1 was not up to date when compared with the documented progress notes in the client record. Progress notes were documented for the dates of 8/7/09, 8/14/09, 8/28/09, 9/4/09, 9/11/09, 9/18/09, 9/25/09 and 10/16/09. However, these dates were not documented on the record of services. The last dated service on the record of services for client record #1 was 7/24/09. The record of services in client record #3 was not up to date when compared with the documented progress notes in the client record. Progress notes were documented for the dates of 8/4/09, 8/11/09, 8/25/09, 9/1/09, 9/8/09, 9/15/09, 9/22/09 and 10/28/09. However, these dates were not documented on the record of services. The last dated service on the record of services for client record #3 was 7/21/09.
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Plan of Correction
A record-keeping training to include a review of the Record of Service will be facilitated to ensure that all staff document progress notes on the Record of Service as required by the Division of Drug and Alcohol Licensure.
All Record of Services documentation and compliance will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings and monitored for three (3) months to ensure compliance, completion, and timelines by the OP Program Director.
Persons Responsible: Division Director, OP Program Director
Timeframe for Completion: January 31, 2010.
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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 case consultation notes in five of six records.
The findings include:
Eight client records were reviewed on November 4, 2009 through November 5, 2009. Case consultation notes were required in six client records. Case consultation notes in client record #1 were due by 8/2/09 and again by 10/2/09. No case consultation notes were documented in client record #1 as of November 5, 2009. Case consultation notes in client record #2 were due by 8/1/09 and again by 10/1/09. No case consultation notes were documented in client record #2 as of November 5, 2009. Case consultation notes in client record #3 were due by 7/22/09 and again by 9/22/09. No case consultation notes were documented in client record #3 as of November 5, 2009. Case consultation notes in client record #4 were due by 8/5/09 and again by 10/5/09. No case consultation notes were documented in client record #4 as of November 5, 2009. Case consultation notes in client record #6 were due by 4/12/09. No case consultation notes were documented in client record #6 as of November 5, 2009. The second case consultation in client record #5 was due by 7/24/09; however, there was no second case consultation documented in client record #5 as of November 5, 2009.
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Plan of Correction
A record-keeping training to include documentation of Case Consultation Notes will be facilitated to ensure that all staff document Case Consultation Notes as required by the Division of Drug and Alcohol Licensure.
All Case Consultation Note documentation and compliance will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings and monitored for three (3) months to ensure compliance, completion, and timelines by the OP Program Director.
Persons Responsible: Division Director, OP Program Director
Timeframe for Completion: January 31, 2010.
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