INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 14, 2008, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Ellen O'Brien Gaiser Addiction Center, 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 and a plan of correction is due on September 15, 2008.
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Plan of Correction
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709.23(a) LICENSURE Project Director
709.23. Project director.
(a) The project director shall prepare and annually update a written manual delineating project policies and procedures.
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Observations
Based on the administrative manual review on 8-11-08 and 8-12-08, the facility failed to present a complete and current operations manual that was free of conflicting information..
Finding:
The recently revised manual did not include consistency between policies and procedures, lacked details in numerous areas, and referred several times to the Assistant Director, but this position does not exist in this organization.
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Plan of Correction
The Project Director and the Administrative Assistant, along with input from the State Licensing Specialist,reviewed the administrative manual and noted any inconsistent policies and/or language. The Administrative Assistant under the direction of both the Clinical and Execitive Director is correcting any errors. The revised administrative manual will accurately reflect all current Gaiser Policies and procedures and will be in full compliance with State and other funding sources' contracts. The manual will be completed by September 30, 2008. |
709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
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Observations
Based on a review of the residential client handbook and client records on 8-13-08, the facility failed to notify the client of their rights in regards to reviewing their own client records.
Finding:
There was no documentation to demonstrate that clients # 1, 2, 3 and 4 were made aware of their right to review their own client record.
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Plan of Correction
Effective 8/14/08 The Executive Director added to the client handbook a complete listing of clients rights including instructions on "Inspecting Your Personal Records". All clients recieve a client handbook when admitted. |
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.
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Observations
Based on a review of the four client records on 8-13-08, the facility failed to provide the individual assessment for each group participant in the group progress notes in three of four client records.
Findings:
There was no documentation of the client's individual participation in group progress notes in client records # 1, 2 and 4.
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Plan of Correction
Effective August 14, 2008 all client group notes are individualized and specific to each client's participation in group therapy sessions. During staffing on 8/14/08, The Clinical director communicated this regulation clearly to each counselor and/or counselor aide. The counselor facilitating the group session will be responisble for the group note. |