INITIAL COMMENTS
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This report is a result of an on-site follow-up inspection to the initial on-site licensure inspection conducted on November 4 - 5, 2009 by staff from the Division of Drug and Alcohol Program Licensure.
The follow-up inspection was conducted on June 23, 2010 by staff from the Division of Drug and Alcohol Program Licensure.
Based on the findings of the on-site follow-up inspection, Gaudenzia DRC 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 July 28, 2010.
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Plan of Correction
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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 client records reviewed.
Eight client records were reviewed on June 23, 2010.
Six records required documentation of an individual treatment plan.
The facility failed to document a treatment plan in client records # 2, 6, and 7.
Client # 2 was admitted to the program on 4/21/10 and is still an active client.
The facility failed to document an individual treatment plan as of the time of review on 6/23/10.
Client # 6 was admitted to the program on 2/23/10 and discharged on 5/5/10.
The facility failed to document an individual treatment plan as of the time of review on 6/23/10.
Client # 7 was admitted to the program on 3/17/10 and discharged on 4/22/10.
The facility failed to document an individual treatment plan as of the time of review on 6/23/10.
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Plan of Correction
Treatment plans will be completed in compliance with Department of Health timeframes by July 30, 2010. The OP charts will be reviewed weekly and monitored during monthly Continuous Quality Improvement (CQI) meetings for three (3) months to ensure compliance, completion, and timelines by the Program Director.
A record-keeping training to include a review of treatment plan standards will be facilitated on August 13, 2010 to ensure that all staff understand Treatment Plan Standards per DOH Policy 709.92 (a).
Persons Responsible: Outpatient Program Director.
Timeframe for Completion: September 30, 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
Due to the original completion date to be in compliance regarding this deficiency it can not be re-evaluated until the next licensing inspection.
Please resubmit the original plan of correction date for the date of completion.
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Plan of Correction
Previous Plan of Correct
A record-keeping training which included a review of the treatment planning systems was facilitated to ensure that all staff document Treatment Plan Updates as required by the Division of Drug and Alcohol Licensure. The training was held on January 18, 2010 and January 20, 2010.
All treatment plan update documentation and compliance timeframes continue to be reviewed weekly and monitored during monthly Continuous Quality Improvement (CQI) for three (3) months to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible: Outpatient Program Director
Timeframe for Completion: April 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 service in four of eight records reviewed.
The findings include:
Eight client records were reviewed on June 23, 2010.
All records required documentation of a record of service.
The facility failed to document a record of service in client records # 1, 2, 6, and 7.
Client # 1 was admitted to the program on 3/17/10.
The comprehensive treatment plan was documented complete on 4/19/10.
The facility did have a record of service sheet in this client record; however, only 3/1/10 was documented on the sheet which did not correspond to the progress notes.
Client # 2 was admitted to the program on 4/21/10.
The facility did have a record of service sheet in this client record; however, only 3/25/10 and 4/21/10 were documented on the sheet which did not correspond to the progress notes.
Client # 6 was admitted to the program on 2/23/10 and discharged on 5/5/10.
The facility failed to document a record of service sheet for this client as of the time of review on June 23, 2010.
Client # 7 was admitted to the program on 3/17/10 and discharged on 4/22/10.
The facility failed to document a record of service sheet for this client as of the time of review on June 23, 2010.
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Plan of Correction
All Record of Services documentation will be compliance with Department of Health timeframes by July 30, 2010. The Record of Service will be reviewed weekly and monitored during monthly Continuous Quality Improvement (CQI) meetings for three (3) months to ensure compliance, completion, and timelines by the Program Director.
A record-keeping training to include a review of the Record of Service will be facilitated on August 13, 2010 to ensure that all staff understand how to document progress notes on the Record of Service per DOH Policy 709.93(a)(3).
Persons Responsible: Outpatient Program Director
Timeframe for Completion: September 30, 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
Due to the original completion date to be in compliance regarding this deficiency it can not be re-evaluated until the next licensing inspection.
Please resubmit the original plan of correction date for the date of completion.
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Plan of Correction
A record-keeping training which included documentation of Case Consultation Notes was facilitated to ensure that all staff document Case Consultation Notes as required by the Division of Drug and Alcohol Licensure. The training was held on January 18, 2010 and January 20, 2010.
All Case Consultation Note documentation and compliance will be reviewed weekly and monitored during monthly Continuous Quality Improvement (CQI) meetings for three (3) months to ensure compliance, completion, and timelines by the OP Program Director.
Persons Responsible: Outpatient Program Director
Timeframe for Completion: April 2010.
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