INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 12, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Gaudenzia DRC 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.
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Observations
The facility failed to provide documentation of a complete and informed consent for client records # 1, 2, 3, 4, 5, and 7. The consent forms provided in the electronic record had a list of agencies including; Pennsylvania Department of Welfare, Community Behavioral Health, In case of emergency, Atlantic Diagnostics, Redwood Toxicology Lab, Pharmatech Inc., Pennsylvania Department of Corrections, Pennsylvania Board of Probation and Parole that did not provide the information that was to be released.
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Plan of Correction
The Intake/Assessment Department will revert back to the Client Consent Forms that was used prior to implementation of the Electronic Health Record system (Avatar). The Consent forms will be reviewed and signed by client and staff and uploaded into the Electronic Health Record of the client.
Consent forms for client #1, 2, 3, 4, and 5 will be redone, signed by client and staff and uploaded to the respective Electronic Health Record.
Client #7 has been successfully discharged from Gaudenzia DRC effective 10/3/18 and unavailable for review and update of Client Consent forms.
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709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
The facility failed to ensure that there was appropriate documentation of written acknowledgment by the client that the client had been made aware of their rights in client record # 3.
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Plan of Correction
During the Intake/Admission process clients are presented with Client Bill of Rights. The Client Bill of Rights is reviewed with the client and the client is asked if they would like a copy of it. If they request a copy it is given to them after it has been signed.
The Intake Supervisor will review intake documentation daily to ensure that the client Bill of Rights has been signed.
The Client Bill of Rights will be reviewed with Client #3 again and it will be signed the date of the review.
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709.92(c) LICENSURE Treatment and rehabilitation services
709.92. 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
The facility failed to provide documentation that the clients received counseling services according to their individual comprehensive treatment plan in 4 of 7 charts reviewed.
Client # 1 was admitted on September 7, 2018 and was still an active client at the time of the inspection. A comprehensive treatment plan was developed with the client on September 21, 2018 that indicated Individual sessions 4 times a month and Group sessions 8 times a month. Progress notes and record of service indicate that the client received 3 individual and no group sessions for the month of October and only 5 group sessions for the month of November.
Client # 3 was admitted on August 16, 2018 and was still an active client at the time of the inspection. A comprehensive treatment plan was developed with the client on August 30, 2018 with the last update on November 2, 2018. The treatment plan indicated Individual sessions weekly and group sessions 3 times weekly between August 30 and November 2, 2018. Progress notes and record of service indicate that the client received no individual sessions after October 15 and did not receive group sessions since the implementation of the treatment plan.
Client # 4 was admitted on October 31, 2018 and was still an active client at the time of the inspection. A comprehensive treatment plan was developed with the client on November 8, 2018 that indicated Individual sessions weekly and Group sessions 3 times weekly. Progress notes and record of service indicate that the client received 1 group session for the week of November 11-17, 18-24 and December 2-8 and no group sessions the week of November 25-December 1.
Client # 5 was admitted on September 6, 2018 and was still an active client at the time of the inspection. A comprehensive treatment plan was developed with the client on September 21, 2018 with the last update on December 4, 2018. The treatment plan indicated Individual sessions weekly and group sessions 3 times weekly between September 21 and December 4, 2018. Progress notes and record of service indicate that the client received no group sessions the weeks of September 23-29, September 30-October 6, October 7-13, 14-20, 21-27, October 28-November 3, November 11-17 and 1 group session November 4-10 and November 25-December 1.
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Plan of Correction
Each participant record shall contain documentation of all services provided to the participant by the project. This information shall be noted on the Record of Services Provided Form. The entries will be signed by the clinician facilitating the service and the participant.
Individual counseling shall occur at least one hour weekly, and shall be documented in the participant record on Individual Counseling Progress Note.
For group sessions, individual notes need not be written for each participant. One group note will suffice provided that it includes a comment relative to each individual's response or participation in the group session.
Level of Care 1 ? (Outpatient ) Group therapy (2 hour session) shall occur at least once weekly and be documented in the participant record on a Group Progress note.
Level of Care 2.1 ? (Intensive Outpatient) Group therapy (3 hour session) shall occur at least three times weekly and shall be documented on a Group Progress note.
Clinical services shall be documented on Record of Service form.
Client #1 chart will be reviewed by Program Director to ensure that notes for services billed for are included. There will be a No Show note entered for missed individual or group sessions.
Client #3 chart will be reviewed by Program Director to ensure that notes for services billed for are included. There will be a No Show note entered for missed individual or group sessions.
Client #4 chart will be reviewed by Program Director to ensure that notes for services billed for are included. There will be a No Show note entered for missed individual or group sessions.
Client #5 chart will be reviewed by Program Director to ensure that notes for services billed for are included. There will be a No Show note entered for missed individual or group sessions.
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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:
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Observations
The facility failed to provide a complete client record to include referral contact and follow-up information.
Client # 1 was admitted on September 7, 2018 and was still an active client at the time of inspection. There was no documentation of a referral contact in the client record.
Client # 2 was admitted on October 30, 2018 and was still an active client at the time of inspection. There was no documentation of a referral contact in the client record.
Client # 3 was admitted on August 16, 2018 and was still an active client at the time of inspection. There was no documentation of a referral contact in the client record.
Client # 4 was admitted on October 31, 2018 and was still an active client at the time of inspection. There was no documentation of a referral contact in the client record.
Client # 6 was admitted on February 16, 2018 and discharged on July 6, 2018. There was no documentation of a follow-up in the client record or the follow up log.
Client # 7 was admitted on July 26, 2018 and discharged on October 3, 2018. There was no documentation of a referral contact follow-up in the client record or follow up log.
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Plan of Correction
All participants are followed up after discharge.
Follow up information shall be conducted for each participant after discharge from the program, unless there is specific participant refusal for follow up. The follow up log binder will house the documentation of each follow up attempt.
Primary Counselors and/or any designee of the Program/Clinical Supervisor or Director shall assume responsibility for participant follow up.
In the case where a participant has been referred to a specific outside resource for continued care post discharge from the project, follow up should be completed via a telephone call with the resource within one week of the participant's initial referral appointment to the resource. Once the attempt has been made and documented in the follow up log binder, a program may consider its obligation to the individual fulfilled.
In instances where the participant refuses follow up, the refusal shall be documented on the Follow Up form.
Where participants are not referred after discharge, the clinical supervisor or their designee will call the participant in 30 days. Contact will be logged in the Follow Up Log binder.
Follow up information shall include the participant's status with the referral resource/resource disposition, sobriety status, 12 step/support group involvement, and overall progress with aftercare goals.
Referral contact/follow up form for Client #1 will be placed in Follow-up Binder.
Referral contact/follow up form for Client #2 will be placed in Follow-up Binder.
Referral contact/follow up form for Client #3 will be placed in Follow-up Binder.
Referral contact/follow up form for Client #4 will be placed in Follow-up Binder.
Referral contact/follow up form for Client #6 will be placed in Follow-up Binder.
Referral contact/follow up form for Client #7 will be placed in Follow-up Binder.
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