INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on June 20, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Gaudenzia Kindred House, 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:
|
Plan of Correction
|
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.
|
Observations
Based on the review of 7 client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in 1 client record.
Client # 1 was admitted on 1/10/17 and was discharged 8/3/17. There were release of information forms signed to the funding source, a urinalysis lab and a government agency, all dated 1/10/17 and expired on 7/31/17. There was documentation that communication was made between the facility and all the agencies between the expiration date and the date of the inspection without an updated, client-signed consent to release information form in place prior to disclosure.
The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
As of June 21, 2018, the Clinical Supervisor met with clinicians to train them to review release of information forms monthly to ensure that the release of information forms are current. Program management will ensure that consent forms are properly dated through ongoing regular chart audits. |
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 a review of client records conducted during the on-site inspection, the facility failed to properly document the frequency of services in 3 of 7 client records.
Client #5 was admitted on 2/14/18, and was active at the time of inspection. The client's individualized treatment plan dated 6/12/18, does not indicate frequency of counseling services to be provided.
Client #6 was admitted on 3/6/18, and was active at the time of inspection. The client's individualized treatment plan dated 6/11/18, does not indicate frequency of counseling services to be provided.
Client #7 was admitted on 3/13/18, and was active at the time of inspection. The client's individualized treatment plan dated 6/14/18, does not indicate frequency of counseling services to be provided.
These findings were reviewed with facility staff as part of the inspection process.
|
Plan of Correction
The electronic treatment plan form is currently undergoing revision to provide space to specify both type and frequency of interventions as well as prompts to remind the clinician to address this area. These revisions will be completed and fully implemented by 7/31/18. Program management will ensure that treatment plans are properly utilized through ongoing regular chart audits. |