INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 2-4, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia, Inc. People With Hope/Short-Term Program 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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705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of fire drill logs, the facility failed to conduct a fire drill during sleeping hours at least once every six months.
The findings include:
The facility's fire drill logs were reviewed on June 3, 2013. The fire drill logs were reviewed from the last survey, June 2012 to May 2013. The only documented fire drill during sleeping hours was conducted on February 28, 2013.
This was discussed with and confirmed by the program supervisor and program director.
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Plan of Correction
A training has been scheduled and will be conducted by the Program Director and Physical Plant Specialist to address conducting fire drills and documentation of fire drill logs. This training will include frequency of fire drills to include at least one every six months during sleeping hours. Program Supervisor will be responsible for providing monthly supervisory follow up and Program Director will be responsible for ongoing oversight. Full compliance will be met effective July 31, 2013 |
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
Based on a review of client records, the facility failed to assure that counseling services were provided according to the individual treatment and rehabilitation plans.
The findings include:
Five client records were reviewed for the provision of clinical services on June 3-4, 2013. Services and treatments are to be provided according to the recommendations in the individual treatment and rehabilitation plan. The facility did not document services according to the individual treatment plan in two out of five client records, specifically # ' s 1 and 2.
Client # 1 was admitted on April 4, 2013. The individual treatment and rehabilitation plan was completed on April 9, 2013. This treatment plan stated the client was to receive individual counseling sessions two times a week. Client #1 has received individual counseling sessions once a week.
Client # 2 was admitted on March 19, 2013. The individual treatment and rehabilitation plan was completed on March 22, 2013. This treatment plan stated the client was to receive individual counseling sessions two times a week. Client #2 has received individual counseling sessions once a week.
The findings were confirmed with the program director.
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Plan of Correction
A training has been scheduled and will be conducted by the Program Director and rogram Supervisor to address documentation. This training will include assuring that counseling services are provided according to the individual treatment and rehabilitation plans. Program Supervisor will be responsible for providing monthly supervisory follow up and Program Director will be responsible for oversight. Full compliance will be met effective July 31, 2013. |
709.53(a)(3) LICENSURE Records of Service
709.53. 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 chronological listing of the various specific services provided to each individual.
The findings include:
Six inpatient records were reviewed for documentation of a record of service on June 3-4, 2013. The facility failed to document services as provided to the clients in four out of six client records, specifically #'s 1, 2, 3, and 5.
Client #1 was admitted into treatment on April 4, 2013. Progress notes for individual session dated: 4/9/13, 4/18/13, 4/23/13, and 4/29/13 were documented in the client's record, however they were not reflected in the record of services for client #1.
Client #2 was admitted to treatment on March 19, 2013. There was no documentation of a record of service in the chart representing client #2.
Client #3 was admitted to treatment on May 20, 2013. A progress note for an individual session dated 5/30/13 was documented in the client's record, however it was not reflected in the record of services for client #3.
Client #5 was admitted to treatment on January 18, 2013 and discharged on April 1, 2013. Progress notes for individual session dated: 3/5/13, 3/20/13, and 3/24/13 were documented in the client's record, however they were not reflected in the record of services for client #5.
The findings were discussed with the program director prior to the exit interview.
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Plan of Correction
A training has been scheduled and will be conducted by the Program Director and Program Supervisor to address documentation. This training will include records of service which document a complete chronological listing of services provided to each individual. The client records for #'s 1,2,3,and 5 have been updated to reflect the services rendered. This was completed on 6/6/13. Program Supervisor will be responsible for monthly supervisory follow up and Program Director will be responsible for ongoing oversight. Full compliance will be met effective July 31, 2013. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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:
(11) Follow-up information.
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Observations
Based upon a review of the facility's policies and procedures and client records, the facility failed to document follow-up information as per their policy.
The findings include:
The policies and procedures manual was reviewed as part of an administrative review that was conducted from May 6-8, 2013.
In reference for the time line for follow-ups the facility ' s policy states:
Within seven days of the date of a referral appointment made for a client leaving treatment, the referral shall be contacted by the Counselor. In the case of a client ending treatment without a referral appointment (ASA, Therapeutic Discharge, Completion who refuses further treatment), the client shall be contacted within 30 days.
Three client records requiring documentation of follow-ups were reviewed on June 4, 2013. One out of three client records did not have documentation of a follow-up, specifically # 6.
Client #6 was admitted into treatment on November 16, 2012 and discharged on February 28, 2013. As of the date of inspection, there was no documentation of a follow-up for client #6.
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Plan of Correction
A training has been scheduled and will be conducted by Program Director and Program Supervisor to address documentation. This training will include documentation of follow up per our policy. A follow up has been documented on client # 6. This follow up was completed on 6/6/2013. Program Supervisor will be responsible for providing supervisory follow up and Program Director will be responsible for ongoing oversight. Full compliance will be met effective July 31, 2013. |