INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on November 2-3, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Inc. Harrisburg Concept 90 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 and a plan of correction is due on December 6, 2010.
|
Plan of Correction
|
709.52(a)(2) LICENSURE Tx type & frequency
709.52. 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
Based on the review of client records and a review of the facility ' s policy manual, the facility failed to document a treatment plan to include type and frequency of treatment and rehabilitation services in six of six client records.
The findings include:
Six client records were reviewed on November 3, 2010 for type and frequency of treatment and rehabilitation services. The facility did not document treatment plans to include type and frequency of treatment services, as per facility policy, in client records # 1, 2, 3, 4, 5 and 6.
The facility ' s policy titled " PROCEDURE FOR INDIVIDUAL TREATMENT & REHABILITATION PLAN " states:
" Included in the action plan will be a statement of the type (individual / group / family therapy, health education, etc.) and frequency (daily, 2-3 x weekly, once, ongoing, etc.) of service in which the client will be involved. "
In client record #1, the treatment plan documented on 9/30/10 did not include type and frequency of treatment and rehabilitation services.
In client record #2, the treatment plan documented on 10/8/10 did not include type and frequency of treatment and rehabilitation services.
In client record #3, the treatment plan documented on 9/15/10 did not include type and frequency of treatment and rehabilitation services.
In client record #4, the treatment plan documented on 9/1/10 did not include type and frequency of treatment and rehabilitation services.
In client record #5, the treatment plan documented on 8/21/10 did not include type and frequency of treatment and rehabilitation services.
In client record #6, the treatment plan documented on 8/16/10 did not include type and frequency of treatment and rehabilitation services.
This is a repeat citation. The facility was cited on 6/15/10 for failing to document type and frequency of treatment and rehabilitation services.
The facility director confirmed that the type and frequency of treatment rehabilitation services were not included in the treatment plans in client records one through six.
|
Plan of Correction
On 11-8-2010 a clinical training was held at Concept 90. The training involved all clinical staff and was facilitated by the Concept 90 Program Supervisor. The training included treatment planning and documentation of type and frequency of rehabilitation services. Included in all treatment plans wil be a statement of the type of treatment such as(individual, group, family), and frequency, (daily, 2x per week, or ongoing, etc) of services that the client will be involved. To ensure compliance with this standard, all treatment plans will be audited by the Program Supervisor for a period of three months on a weekly basis. If after three months type and frequency has been included consistently in all plans, the Program Supervisor will audit treatment plans on a monthly basis. |
709.53(a)(5) LICENSURE Progress Notes
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:
(5) Progress notes.
|
Observations
Based on the review of client records and a review of the facility ' s policy manual, the facility failed to document progress notes in six of six client records.
The findings include:
Six client records were reviewed on November 3, 2010 for group progress notes. The facility did not document group progress notes to include a comment relative to each individual's response or participation, as per facility policy in client records # 1, 2, 3, 4, 5 and 6.
The facility ' s policy titled " CLIENT COUNSELING LOGS / PROGRESS NOTES " states:
" For group sessions, individual notes need not be written for each client. One group note will suffice provided that it includes a comment relative to each individual ' s response or participation in the group session. Group Feedback sheets are used to document the type and focus of the group, the client's specific feedback and the Counselor's assessment of the client's involvement. "
In client record #1, the facility did not document group progress notes to include a comment relative to each individual's response or participation on, September 1, 3, 15, 15, 20, 22, October 1, 4, 11, 18, 20, 22, 25 and 27,
In client record #2, the facility did not document group progress notes to include a comment relative to each individual's response or participation on, October 6, 11, 13, 18, 20, 22 and 25.
In client record #3, the facility did not document group progress notes to include a comment relative to each individual's response or participation on, September 15, 20, 22, October 1, 4, 6, 4, 18, 22 and 27.
In client record #4, the facility did not document group progress notes to include a comment relative to each individual's response or participation on, September 3, 10, 15, 20 ,22, 29, October 1, 4, 6, 12, 18, 20, 22, 25 and 27.
In client record #5, the facility did not document group progress notes to include a comment relative to each individual's response or participation on, August 18, 20, 25, September 1, 3, 10, 15, 20, 22, October 1, 4, 6, 20 and 22.
In client record #6, the facility did not document group progress notes to include a comment relative to each individual's response or participation on, August 20, 25, 30, September 1, 3, 10 15, 20, October 1, 4, 6 and 11.
This is a repeat citation. The facility was cited on 6/15/10 for failing to document group progress notes.
The facility director confirmed that the facility did not document group progress notes to include a comment relative to each individual's response or participation in client records one through six.
|
Plan of Correction
On 11-8-2010 a clinical training was held at Concept 90. The training involved all clinical staff and was facilitated by the Concept 90 Program Supervisor. Included in the training was training specific to the proper documentation of progress notes. A progress note will be written for each group. All progress notes will include a comment relative to each clients response or participation in the group session. Compliance to this standard will be monitored by the Program Supervisor. The Program Supervisor will audit all group notes for a period of six months for compliance. If group notes consistantly meet the standard after the six month audit the Program Supervisor wil then include progress notes in the monthly chart review. |
709.14(b)(5) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
|
Observations
Based on a review of the facility ' s Monthly Statistical Reports and an interview with the facility director, the facility failed to notify the Department within 90 days of the occurrence of a change in the authorized maximum client capacity.
The findings include:
The facility ' s Monthly Statistical Reports were reviewed on November 2, 2010. The facility ' s authorized maximum capacity for Inpatient Non-Hospital clients is 42. The Monthly Statistical Reports for July 2010 and August 2010 indicate days where the number of clients exceeds the authorized maximum capacity of 42 clients.
The facility ' s capacity exceeded 42 clients on July 5 (43), 27 (43), 28 (43), 29 (43), 30 (43) and 31 (43).
The facility ' s capacity exceeded 42 clients on August 1 (43) and August 2 (44)
An interview with the facility director on November 2, 2010 confirmed that the monthly statistical reports were correct, and the facility exceeded the authorized maximum client capacity without notifying the Department of the increase.
This is a repeat citation. The facility was cited on 6/15/10 for exceeding the authorized maximum client capacity.
|
Plan of Correction
The facility will refrain from exceeding the authorized maximum capacity (42). Additionally, the facility will notify the Department within 90 days of any occurrence in the change of the authorized maximum capacity. To ensure compliance to this standard the facility will refrain from setting up or gaining access to any extra beds. This will be monitored by the Program Director the Division Director, and the Regional Director. In addition, the Program Director will work in conjunction with the Intake Specialist to ensure that the daily census does not exceed forty two (42). An administrative meeting will be held weekly, involving the Administrative Coordinator, Intake Specialist, and Program Director to review the daily census. This meeting will occur on an ongoing basis and the results of the meeting will be sent to the Division and Regional Directors. |