INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 10, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gaudenzia 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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709.53(a)(8) LICENSURE Case Consultation 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to have a complete client record on an individual which includes information relative to the client's involvement with the project including case consultation notes every 90 days as per their policy, in four out of five applicable records reviewed.
Client #1 was admitted on November 7, 2022 and was still current at the time of the inspection. There was no documentation of a case consultation in the record.
Client #2 was admitted on January 18, 2023 and was still current at the time of the inspection. There was no documentation of a case consultation in the record.
Client #6 was admitted on November 19, 2022 and discharged on August 1, 2022. There was no documentation of a case consultation in the record.
Client #7 was admitted on September 12, 2022 and discharged on April 26, 2023. There was no documentation of a case consultation in the record.
This is a repeat citation from the May 5, 2022 onsite licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will ensure that all client records will be complete and will include case consultations, at minimum every ninety days, as per their organization's policy and procedures.
Program Director will utilize the organizations EHR system to track and generate the appropriate forms for each client record.
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709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to have a complete client record on an individual which includes information relative to the client's involvement with the project including follow up information within seven days as per their policy, in one out of three applicable records reviewed.
Client #7 was admitted on September 12, 2022 and discharged on April 26, 2023. There was no documentation of follow up information in the record.
This is a repeat citation from the May 5, 2022 onsite licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will ensure client follow up contacts be conducted within seven days after client discharge, in accordance with internal policy and procedures.
Program Director will utilize organization's EHR weekly reports to track and complete follow up contacts, for all discharges. |