INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on July 2, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Gaudenzia, 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:
|
Plan of Correction
|
709.28 (c) 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.
|
Observations
The facility failed to document the name of the person, agency, or organization to whom the disclosure was to be made to on a consent form in one of fourteen client records.
Client # 10 was admitted on January 5, 2018 and was active at the time of inspection. The release of information form was signed and dated by the client on January 5, 2018.
The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Program Director will conduct an in service training on 8/17/18 with clinical staff on the requirements that all consents must be filled out in their entirety.
Program Director will select 20 % of the current client files randomly each week to review consent forms for compliance.
The consent in question will be voided and initialed by the Program Director and kept in the client file. This will verify that the corrective action is completed.
The Division Director will oversee the compliance of this action. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
|
Observations
The facility failed to include documentation of a preliminary treatment plan during the intake and admission period in two of seven applicable client records.
Client #10 was admitted on January 5, 2018 and was active at the time of inspection.
Client #14 was admitted on December 28, 2017 and was discharged May 3, 2018.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Program Director will conduct an in service training to enforce the requirement that all clients must have a preliminary treatment plan completed at time of admission into IOP or OP treatment. In service will be conducted on 8/17/18.
To ensure this does not recur all initial treatment plans will be forwarded to Program Director prior to completion of the first session.
Compliance will be ensured by Division Director. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
|
Observations
The facility failed to properly document the type and frequency of services on the client's individual treatment plan in three of seven applicable client records.
Client #8 was admitted on December 5, 2017, and was active at the time of inspection. The comprehensive treatment plan was dated June 27, 2018.
Client #9 was admitted on January 23, 2018 and was active at the time of inspection. The comprehensive treatment plan was dated June 12, 2018.
Client #10 was admitted on January 5, 2018 and was active at the time of inspection. The individualized treatment plan May 16, 2018.
These findings were reviewed with facility staff as part of the inspection process.
|
Plan of Correction
The electronic treatment plan form is currently undergoing revision to provide space to specify both type and frequency of interventions as well as prompts to remind the clinician to address this area. These revisions will be completed and fully implemented by 08/17/2018.
Comprehensive treatment plans are due within 30 days of admission. Once the comprehensive is completed it will be forwarded for Program Director signature before the end of the treatment planning session.
Program management will ensure that treatment plans are properly utilized through ongoing regular chart audits.
|
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.
|
Observations
The facility failed to provide treatment plan updates within the regulatory timeframe in four of seven applicable client records.
Client #8 was admitted on December 5, 2017 and was active at the time of inspection. The comprehensive treatment plan was completed on December 5, 2017 and the next update was due no later than February 5, 2018. However, the update was not completed until June 27, 2018.
Client #10 was admitted on January 5, 2018 and was active at the time of inspection. The comprehensive treatment plan was completed on March 6, 2018 and the next update was due no later than May 6, 2018. However, the update was not completed until May 16, 2018.
Client #11 was admitted on November 11, 2017 and was discharged on May 10, 2018. The comprehensive treatment plan was completed on December 19, 2017 and the next update was due no later than February 19, 2018. However, the update was not completed prior to discharge.
Client #13 was admitted on May. 26, 2017 and was discharged on October 2, 2017. The comprehensive treatment plan was completed on July 7, 2017 and the next update was due no later than September 7, 2017. However, the update was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Program Director will conduct an in service training on treatment planning and focus on abiding with regulatory time frames. This in service will be conducted on 8/24/18.
Treatment plan updates are due every 60 days from the date of the last update or comprehensive treatment plan. Completed treatment plans must be forwarded to the Program Director for signature prior to the end of the treatment planning session.
Division Director will oversee the compliance of this requirement. |
709.93(a) 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:
|
Observations
The facility failed to provide follow up information in the client's complete record in three of seven applicable client records.
Client #11 was admitted on November 14, 2018 and was discharged on May 10, 2018.
Client #13 was admitted on May 25, 2017 and was discharged on October 2, 2017.
Client #14 was admitted on December 28, 2017 and was discharged on May 3, 2018.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Program Director will have an in service training to discuss follow up procedures and the requirement of completing the follow up form for every client that discharges from treatment within the required time frame. This in service will occur on 8/24/18.
Follow ups need to occur within the first week of discharge. All discharged charts will be reviewed by the Program Director within 7 days to ensure all documentation is present to include the follow up form.
Compliance will be overseen by the Division Director. |