INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 29, 2016 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 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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709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
The facility failed to document a psychosocial evaluation in 4 of 10 client records
Ten client records were reviewed on July 29, 2016. All of the client records reviewed were required to include documentation of a psychosocial evaluation. Client records #7, 8, 9 and 10 did not include documentation of a psychosocial evaluation.
Client #7 was admitted to treatment on March 29, 2016.
Client #8 was admitted to treatment on May 16, 2016.
Client #9 was admitted to treatment on April 28, 2016.
Client #10 was admitted to treatment on March 21, 2016.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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
The facility failed to review and update treatment and rehabilitation plans at least every 60 days in 4 of 8 client records.
Ten client records were reviewed on July 29, 2016. Eight of the clients reviewed were in treatment for the period of time requiring a treatment plan update. Client records #3, 4, 5 and 6 did not include documentation of treatment plan updates at least every 60 days.
Client #3 was admitted on April 5, 2016 and discharged on July 1, 2016. The initial treatment plan was completed on April 5, 2016. A treatment plan review/update was due to be completed by June 5, 2016. There was no treatment plan review/update in client record #3.
Client #4 was admitted on April 18, 2016 and discharged on July 13, 2016. The initial treatment plan was completed on April 18, 2016 and review/update was completed on May 6, 2016. Another treatment plan review/update was due to be completed by July 6, 2016. There was no July treatment plan review/update in client record #4.
Client #5 was admitted on March 3, 2016 and discharged on July 21, 2016. The initial treatment plan was completed on March 3, 2016 and a review/update was completed on March 22, 2016. Another treatment plan review/update was due to be completed by May 22, 2016. There was no May treatment plan review/update in client record #5.
Client #6 was admitted on March 9, 2016. The initial treatment plan was completed on March 28, 2016 and a review/update was completed on June 13, 2016; however, the treatment plan review/update was due to be completed by May 28, 2016.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
The facility failed to document a physician signature on treatment plans for publicly funded clients in one of one client records reviewed on July 29, 2016.
Client #8 was admitted on May 16, 2016, and was publicly funded. The initial treatment plan was completed on May 26, 2016 and an update was completed on June 30, 2016. There was no physician signature on either the treatment plan or the update.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |