INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 25, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Erie, Inc. was found to be not 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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705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection conducted on October 25, 2017, the facility failed to keep the facility in good repair at all times.
The sidewalk leading to the outpatient entrance from the street was severely damaged and had a large section of the slab missing which created a tripping hazard.
This is also applicable to regulation 705.22 (2) Physical Plant Standards for Non-Residential Facilities but is being cited under this regulation as to avoid a double citation.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Operations Manager will contact two local vendors to acquire estimates to replace the sidewalk area that is damaged by 11/15/2017.
Operations manager will review estimates and work to be completed with Division Director by 11/21/2017.
Operations Manager will schedule with the chosen contractor to complete the repairs on the first available date.
Operations Manager will tape off damaged area by 11/09/2017 and remove the caution tape once area is repaired. |
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
The facility failed to document written acknowledgement by the client that they were notified of all of their rights in thirteen of thirteen client records reviewed on October 25, 2017.
There was no documentation that the client was informed that the project, facility or clinical director would document the reason for removal from the client's record of any material deemed detrimental to the client in client records # 1-13.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Division Director will review and adjust agency policy as needed to ensure all required client rights are listed in rights that are reviewed with clients upon admission. Division Director will complete this review by 11/14/2017.
Division Director will review agency policy/client rights with the Program Director by 11/17/2017.
Program Director will review updated policy/client rights with all staff by 11/21/2017.
Staff will begin using updated policy/client rights with all clients starting 11/22/2017.
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709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Seven in-patient client records were reviewed on October 25, 2017. The facility failed to update the treatment plan every 30 days in three of seven applicable records.
Client #4 was admitted on June 1, 2017 and discharged on October 17, 2017. The comprehensive treatment plan was documented on June 12, 2017; a treatment plan update was due by July 12, 2017 but was not documented until July 14, 2017; Additionally, a treatment plan update was documented on August 1, 2017; another update was due by September 1, 2017 but was not documented until September 9, 2017.
Client #6 was admitted on February 27, 2017 and discharged on May 30, 2017. The comprehensive treatment plan was documented on March 10, 2017; a treatment plan update was due by April 10, 2017 but was not documented until April 11, 2017.
Client #7 was admitted on April 13, 2017 and discharged on October 13, 2017. A treatment plan update was documented on May 26, 2017; a treatment plan update was due by June 26, 2017 but was not documented until July 7, 2017; Additionally, a treatment plan update was documented on August 9, 2017; another update was due by September 9, 2017 but was not documented until September 21, 2017.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Program Director will review required time frames with all clinical staff as it relates to updated treatment plans. Program Director will meet with clinical staff to review the required time frames by 11/23/2017.
Program Director will complete monthly chart audits beginning in November 2017 looking specifically at updated treatment plans and ensuring they are being updated in a timely manner.
Program Director will share the monthly chart audit results in the agencies monthly quality improvement meeting starting 12/20/2017. Program Director will identify any continued issues and discuss solutions in the monthly quality improvement meeting if needed or as applicable. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Seven inpatient client records were reviewed on October 25, 2017. The facility failed to provide counseling according to the treatment plan in three of seven client records reviewed.
Clients # 1, 6 & 7 did not receive weekly individual counseling sessions as indicated on the treatment plans.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Program Director will meet with all clinical staff and train staff on proper documentation of services and making sure that services that are documented on the treatment plans are being provided. The Program Director will complete this training by 11/23/2017.
Program Director will complete monthly chart audits starting in November 2017 to ensure services documented on the treatment plans are being provided to the clients as documented.
Program Director will share the results of the monthly chart audits in the agencies monthly quality improvement meeting starting on 12/20/2017. |
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
Six outpatient client records were reviewed on October 25, 2017. The facility failed to update the treatment plan every 60 days in two of six applicable records.
Client #8 was admitted on June 1, 2017 and was an active client at the time of the licensing inspection. A treatment plan update was documented on August 22, 2017; another update was due by October 22, 2017 but was not documented at the time of the inspection.
Client #12 was admitted on May 19, 2017 and discharged on September 22, 2017. The comprehensive treatment plan was documented on July 7, 2017; a treatment plan update was due by September 7, 2017 but was not documented until September 8, 2017.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Program Director will meet with the outpatient clinical staff and review required time frames to complete treatment plan updates. Program Director will complete this meeting by 11/23/2017.
Program Director will complete monthly chart audits to ensure that updated treatment plans are being completed every 60 days with outpatient clients. These monthly chart audits will begin in November 2017.
Program Director will share the chart audit results every month in the agency monthly quality improvement meeting starting on 12/20/2017. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Six outpatient client records were reviewed on October 25, 2017. The facility failed to provide counseling according to the treatment plan in five of six client records reviewed.
Clients # 1, 2, 3, 4 & 5 did not receive weekly individual counseling sessions as indicated on the treatment plans.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Program Director will meet with outpatient clinical staff and review/train clinical staff on the fact that services that are documented on the treatment plan need to occur as stated. Program Director will meet with clinical staff by 11/23/2017.
Program Director will complete monthly chart audits to ensure services are being provided to clients according to treatment plans. The monthly chart audits will begin in November 2017.
Program Director will report monthly chart audit results in the agencies monthly quality improvement meeting starting 12/20/2017 |
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
Six outpatient client records were reviewed on October 25, 2017. The facility failed to document a complete client record in four of six applicable records.
The record of service was missing or incomplete in client records #9, 10, 11 & 12.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Program Director will conduct a training with clinical staff by 11/23/2017 reviewing all required documentation for a complete file including record of service and all other required documents.
Program Director will ensure records are complete by completing monthly chart audits beginning November 2017.
Program Director will meet with clinical staff as needed if any continued documentation issues are identified in the monthly chart audits. |