INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 1-4, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Erie Inc., Girard Satellite Office 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 July 3, 2009.
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Plan of Correction
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709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of the client records, the facility failed to document a complete medical history in six of eight client records.
The findings include:
Eight client records were reviewed on June 2, 2009. A complete medical history which includes a personal history, family history, and a history of symptoms and illnesses, was required in eight client records. The facility failed to document a complete medical history in client records # 1, 3, 4, 5, 7 and 8.
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Plan of Correction
A medical history addendum form has been added to all file medication sections to be completed upon intake. The Program Supervisor will train staff and monitor the correct use of this form.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of the client records, the facility failed to document a treatment plan update in one of four client records, and failed to include an assessment of the clients' progress on the goals of the treatment plan in one of four client records.
The findings include:
Eight client records were reviewed on June 2, 2009. A treatment plan update which includes an assessment of the clients' progress on the goals of the treatment plan was required in four client records. Client record #1 had a treatment plan update which was due on 5-4-09, and it was not documented. Client record #6 documented a treatment plan update but it did not include an assessment of the clients' progress on the goals of the treatment plan.
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Plan of Correction
The Program Supervisor will utilize the weekly staff meetings to re-train clinical staff on the correct procedure for treatment plans. This will be reviewed by the supervisor through the monthly PI process.
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709.93(a)(2) 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:
(2) Medication records.
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Observations
Based on a review of the client records, the facility failed to document a complete medication record in three of seven client records.
The findings include:
Eight client records were reviewed on June 2, 2009. A complete medication record which includes the medication name, dose and frequency of use was required in seven client records. Client record # 1, 2, and 3 included medication records which only listed the medication name.
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Plan of Correction
An addendum has been added to the medical section to include all medication information. The Program Supervisor will train staff and monitor this process. |