INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 6, 2014 by staff from the Division of Drug and Alcohol Program Licensure. 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:
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Plan of Correction
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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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in 3 of 10 records reviewed.
The findings included:
Ten client records requiring informed and voluntary consents for the release of information were reviewed on May 6, 2014. The facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in client record #'s 2, 6, and 9.
Client #2 was admitted to treatment on 09/26/2013 and was still active as of the date of the inspection. There was a disclosure of information to the urinalysis lab on 01/16/2014 and there was no signed consent to release information in the client record prior to the disclosure.
Client #6 was admitted to treatment on 09/23/2013 and was discharged on 12/16/2013. There was a disclosure of information to the urinalysis lab on 09/23/2013 and there was no signed consent to release information in the client record prior to the disclosure.
Client #9 was admitted to treatment on 02/13/2013 and was discharged on. There was a disclosure of information to the urinalysis lab on 08/28/2013 and there was no signed consent to release information in the client record prior to the disclosure.
The Facility Director confirmed the findings.
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Plan of Correction
Informed and voluntary written consent will be obtained from clients prior to facility staff disclosing information. All copies of consents to disclose information will be in the client record.
Clinical Supervisor will review the confidentially regulations with all staff in a meeting on June 6, 2014. Staff will sign off that they are aware of this regulation. To further insure compliance the Clinical Supervisor and Division Director will review client records on a monthly basis. |
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 develop an individual treatment and rehabilitation plan with the client in three of ten client records reviewed.
The findings include:
Ten client records requiring documentation of a comprehensive individual treatment and rehabilitation plan were reviewed on May 06, 2014. The facility failed to document comprehensive individual treatment and rehabilitation plans in client records # 1, 2, and 10.
Client # 1 was admitted on 02/25/2014 and was still an active client as of the date of the on-site inspection. A preliminary treatment and rehabilitation plan was signed and documented on 02/25/2014; however, a comprehensive treatment and rehabilitation plan was not documented in the client record as of the date of the inspection.
Client # 2 was admitted on 09/26/2013 and was still an active client as of the date of the on-site inspection. A preliminary treatment and rehabilitation plan was signed and documented on 09/26/2013; however, a comprehensive treatment and rehabilitation plan was not documented in the client record as of the date of the inspection.
Client # 10 was admitted on 06/18/2013 and was discharged on 09/03/2013. A preliminary treatment and rehabilitation plan was signed and documented on 06/18/2013; however, a comprehensive treatment and rehabilitation plan was not documented in the client record as of the date of the inspection.
The Facility Director confirmed the findings.
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Plan of Correction
An all staff in service training will be held on June 6, 2014 to address clinical staff on treatment management procedures specific to the treatment planning process. All staff will be directed to develop comprehensive treatment plans with the client within 30 days of admission and shall be driven by the client's self assessed SNAP goals.
The Clinical Supervisor will review treatment plans for compliancy during the CQI process monthly. Clinical staff will be monitored monthly in regular supervisory sessions. |