INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 26 - 27, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Ellen O'Brien Gaiser Addiction Center 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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709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on a review of the policy and procedure manual, the facility failed to have the project director sign a written manual delineating project policies and procedures. The last documented sign off was 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director will review policy and procedure manual every September with board executive committee and seek board chair signature to store in policy manual, in addition to Project Director annual signature in the manual. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document a treatment plan which includes the proposed type of support service in six of six applicable client records, Client # 1, 2, 3, 4, 5, and 6.
Client # 1 was admitted on February 11, 2021 and discharged on May 25, 2021. The treatment plan dated April 14, 2021 did not include the proposed type of support service.
Client # 2 was admitted on March 16, 2021 and discharged on July 12, 2021. The treatment plan dated April 22, 2021 did not include the proposed type of support service.
Client # 3 was admitted on May 7, 2021. The treatment plan dated May 7, 2021 did not include the proposed type of support service.
Client # 4 was admitted on May 21, 2021 and discharged on August 2, 2021. The treatment plan dated May 21, 2021 did not include the proposed type of support service.
Client # 5 was admitted on March 25, 2021 and discharged on July 15, 2021. The treatment plan dated April 22, 2021 did not include the proposed type of support service.
Client # 6 was admitted on July 14, 2021. The treatment plan dated August 5, 2021 did not include the proposed type of support service.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will add support services document onto treatment plan by October 1, 2021, ensuring that clinicians review and document support services for the clients. Clinical Director will review this change at clinical staffing throughout September with clinicians. All active clients will have a support service document in their next treatment plan update and it will be reviewed with them upon addition. Clinical Director will performed chart reviews monthly to ensure the documentation is included in each chart record. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on one of one applicable client records reviewed, the facility failed to document an aftercare plan.
Client # 1 was admitted on February 11, 2021 and discharged on May 25, 2021. An aftercare plan was not documented in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will perform audits of outpatient charts to ensure that all aftercare plans are documented for clients. Beginning in September, Clinical Director will review aftercare requirements and planning during clinical staffing meetings with clinicians. |