INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 18, 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 DRC 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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705.3 LICENSURE Living rooms and lounges.
705.3. Living rooms and lounges.
The residential facility shall contain at least one living room or lounge for the free and informal use of clients, their families and invited guests. The facility shall maintain furnishings in a state of good repair.
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Observations
Based on a physical plant inspection on September 18, 2023, the facility failed to maintain the furnishings of the lounge in a state of good repair, as the couch cushions were ripped and torn.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 10/6/2023 Division Director ordered new furniture to replace the existing furniture.
The Program Director will conduct a documented weekly walkthrough of the facility to ensure the furniture is in good condition.
The Division Director will conduct a bi-weekly walkthrough of the facility to ensure the furniture is in good condition. If issues are noted, the Division Director will ensure that furniture is repaired or replaced if needed.
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705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection on September 18, 2023, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times. The communal bathroom on the fifth floor had a hole in the wall, loose wood paneling that was separating from the wall, and a loose radiator cover that was separating from the wall. The shower in the shared bathroom on the seventh floor contained peeling paint and mold on each wall. The bathroom in room 704 had debris from paint and plaster throughout the bathroom, as well as cracks in the shower tiles.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 9/25/2023, renovations to address all noted issues began with an anticipated completion date of 11/6/2023.
The maintenance department will conduct documented monthly site inspections and address any areas of need.
The Program Director will conduct documented weekly walkthroughs and report any noted maintenance issues immediately.
The Division Director and QA Manager will conduct documented quarterly site visits and report any findings to the Deputy Director to be addressed as appropriate.
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705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection on September 18, 2023, the facility failed to ensure that heaters were permanently mounted as space heaters were found in the seventh floor counselor office, and bedrooms 708/709 and 711.
This is a repeat citation from the December 9, 2022 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The space heaters were immediately removed from the offices on 09/18/2023, the date of the inspection.
The Division Director will review 705.8 with the newly hired Program Director during a documented supervision session after they begin on 10/30/23.
The Program Director will conduct a documented weekly walkthrough of the facility to ensure that there are no portable heaters in offices or resident rooms.
The Division Director will conduct bi-weekly walkthrough to ensure there are no heaters in the offices or in the rooms.
The QA Manager and Deputy Director will perform quarterly inspections of the physical site. Any findings will be addressed immediately by the Deputy Director.
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705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based on a physical plant inspection on September 18, 2023, the facility failed to ensure that exits from the facility were unobstructed as one of the emergency exit stairwells led down to a door that was propped open by a stack of extra chairs that obstructed the exit door.
This is a repeat citation from the December 9, 2022 annual licensing renewal inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Maintenance Dept. will perform weekly safety checks to ensure that all emergency exit stairwells are unobstructed, and doors are unlocked.
The Division Director will review 705.10 with the newly hired Program Director during a documented supervision session after they begin on 10/30/23.
The QA Manager will perform a quarterly inspection of the physical site.
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705.10 (a) (1) (v) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
Based on a physical plant inspection on September 18, 2023, the facility failed to light interior exits and stairs at all times as a light in the seventh floor emergency exit stairwell was unlit.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
The Maintenance Dept. will perform documented monthly safety checks to ensure the lighting is functioning correctly.
The Division Director will review 705.10 with the newly hired Program Director during a documented supervision session once they begin. The light was fixed on 10/16/2023
The QA Manager will perform a quarterly inspection of the physical site and will report any findings to the Deputy Director to be addressed immediately.
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705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill logs from January 2023 through August 2023, the facility failed to prepare alternate exit routes as the same exit route was documented in each drill.
This is a repeat citation from the December 9, 2022 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will ensure that alternate exit routes are used during monthly fire drills. These will be documented on the fire drill grid.
The Division Director will review 705.10 with the newly hired Program Director during a documented supervision session once they begin.
The CQI Manager will review fire drills logs quarterly and will inform the Program Director will records do not reflect that alternate routes are used.
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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of eight client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients in one of one applicable record reviewed.
Client # 3 was admitted on April 17, 2023 and was discharged Against Staff Advice (ASA) on May 12, 2023. The facility failed to follow their policy related to ASA discharges of calling the Emergency Contact within twelve hours.
This is a repeat citation from the December 9, 2022 annual licensing renewal inspection.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
Plan of Correction:
The Division Director will prove training to staff regarding the completion of a notification call to the emergency contact of any client who leaves against staff advice.
The program was already implementing an internal remediation plan to correct clinical deficiencies noted through our internal CQI processes.
A new Clinical Supervisor was hired in September 2023. A new Program Director has been hired and will begin on 10/30/23.
The Clinical Supervisor will conduct biweekly clinical chart audits.
The Program and Division Directors will complete monthly clinical chart audits.
The CQI Manager and Deputy Director will complete quarterly quantitative and qualitative clinical chart reviews.
Any findings of these audits will be addressed with the clinician in a documented clinical supervision session, and corrected within 48 hours.
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709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of five personnel records, the facility failed to ensure that personnel records contained a reviewed and signed annual written staff performance evaluations in two of four applicable records reviewed.
Employee # 4 has been in the counselor position since July 15, 2022 and is current in that position. The annual staff performance evaluation was not signed by the employee.
Employee # 5 has been in the counselor position since August 8, 2022 and is current in that position. The annual staff performance evaluation was not signed by the employee.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will review all staff performance evaluations with each staff member on an annual basis during the month of January to ensure that all are signed at that time.
The CQI Manager will review completed evaluations twice per year.
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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.
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Observations
Based on a review of eight client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in two records reviewed.
Client # 6 was admitted on August 17, 2023 and was active at the time of the inspection. Per a discussion with the Facility Director, information such as client progress and prognosis were disclosed to the funding source, however, the consent to release information form to the funding source signed by the client on August 17, 2023, did not allow for the release of that information.
Client # 7 was admitted on August 25, 2023 and was active at the time of the inspection. Per a discussion with the Facility Director, information such as client progress and prognosis were disclosed to the funding source, however, the consent to release information form to the funding source signed by the client on August 25, 2023, did not allow for the release of that information.
This is a repeat citation from the December 9, 2022 and December 14, 2021 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
Directly following the audit, the Intake Coordinator was trained on regarding this regulation.
Any missing documentation in active files will be completed no later than 10/20/23
The Intake Coordinator will complete all required consents, particularly for funding sources and labs within the established timeframe.
The program was already implementing an internal remediation plan to correct clinical deficiencies noted through our internal CQI processes.
A new Clinical Supervisor was hired in September 2023. A new Program Director has been hired and will begin on 10/30/23.
The Clinical Supervisor will conduct biweekly clinical chart audits.
The Program and Division Directors will complete monthly clinical chart audits.
The CQI Manager and Deputy Director will complete quarterly quantitative and qualitative clinical chart reviews.
Any findings of these audits will be addressed with the clinician in a documented clinical supervision session, and corrected within 48 hours.
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709.28 (c) (2) 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. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of eight client records, the facility failed to ensure that informed and voluntary consent to release information forms included the specific information to be disclosed in six records reviewed.
Client # 1 was admitted on January 18, 2023 and was discharged on March 20, 2023. The record contained consent to release information forms to the funding source, lab, pharmacy, and two government agencies signed by the client on January 18, 2023, that were missing the specific information to be disclosed.
Client # 2 was admitted on May 4, 2023 and was discharged on May 9, 2023. The record contained consent to release information forms to the funding source, lab, pharmacy, and two government agencies signed by the client on May 5, 2023, that were missing the specific information to be disclosed.
Client # 3 was admitted on April 17, 2023 and was discharged on May 12, 2023. The record contained consent to release information forms to the funding source, lab, pharmacy, and two government agencies signed by the client on April 17, 2023, that were missing the specific information to be disclosed.
Client # 4 was admitted on June 7, 2023 and was discharged on July 7, 2023. The record contained consent to release information forms to the funding source, lab, pharmacy, and two government agencies signed by the client on June 8, 2023, that were missing the specific information to be disclosed.
Client # 5 was admitted on August 16, 2023 and was active at the time of the inspection. The record contained consent to release information forms to the funding source, lab, pharmacy, and two government agencies signed by the client on August 16, 2023, that were missing the specific information to be disclosed.
Client # 8 was admitted on March 15, 2023 and was discharged on April 14, 2023. The record contained consent to release information forms to the funding source, lab, pharmacy, and two government agencies signed by the client on March 15, 2023, that were missing the specific information to be disclosed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
Directly following the audit, the Intake Coordinator was trained on regarding this regulation.
Any missing documentation in active files will be completed no later than 10/20/23
The Intake Coordinator will complete all required consents, particularly for funding sources and labs within the established timeframe.
The program was already implementing an internal remediation plan to correct clinical deficiencies noted through our internal CQI processes.
A new Clinical Supervisor was hired in September 2023. A new Program Director has been hired and will begin on 10/30/23.
The Clinical Supervisor will conduct biweekly clinical chart audits.
The Program and Division Directors will complete monthly clinical chart audits.
The CQI Manager and Deputy Director will complete quarterly quantitative and qualitative clinical chart reviews.
Any findings of these audits will be addressed with the clinician in a documented clinical supervision session, and corrected within 48 hours.
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709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on a physical plant inspection on September 18, 2023, the facility failed to ensure that drugs for external use were stored separately from oral drugs as two tubes of topical medications were stored with oral medications in the medication cabinet.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Nursing will train medical staff on appropriate medication storage protocol no later than 10/20/23.
Nursing staff will separate topical medications from oral medications in separate storage lockers.
Nursing staff will monitor storage bins daily to ensure that medications are properly stored.
The CQI Manager will review medication storage practices during quarterly physical site inspections
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709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
Based on a review of eight client records, the facility failed to follow their policy and procedures related to medication administration and recordkeeping in three of six applicable records reviewed. The facility policy indicates that staff will document on the medication administration record (MAR) the reason a medication was not given.
Client #5 was admitted on August 16, 2023 and was active at the time of the inspection. The MAR did not document the reason medications were not administered on August 22, 2023, August 23, 2023, August 24, 2023, and August 26, 2023 through September 1, 2023.
Client # 6 was admitted on August 17, 2023 and was active at the time of the inspection. The MAR did not document the reason medications were not administered on September 7, 2023 through September 9, 2023, and September 16, 2023.
Client # 7 was admitted on August 25, 2023 and was active at the time of the inspection. The MAR did not document the reason medications were not administered on September 4, 2023, September 7, 2023 through September 9, 2023.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Nursing provided training for medical staff on how to properly document refused medications via the eMAR in our electronic health record.
The Director of Nursing will perform monthly reviews of a sample of eMARs to ensure compliance.
The CQI Manager will conduct reviews of the medical documentation in a sample of charts on a quarterly basis.
Any issues noted will be addressed with the nurse in a documented supervision session.
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709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of eight client records, the facility failed to document that the client was notified, in writing, of the facility's decision to involuntarily terminate the client's treatment at the project in one of one applicable record reviewed.
Client # 2 was admitted on May 4, 2023 and was involuntarily discharged on May 9, 2023. There was no documentation that the client was notified, in writing, of the facility's decision to involuntarily terminate.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counselors will complete the Notification of Involuntary Termination Form in our electronic health record, inform the client of the involuntary termination, and provide the client with a written copy.
The Clinical Supervisor will run the "Details of Discharge" report monthly and audit the charts of clients who are involuntarily terminated to ensure that the form has been completed and provided to the client.
A new Clinical Supervisor was hired in September 2023. A new Program Director has been hired and will begin on 10/30/23.
All new staff will receive treatment planning training upon hire, and ongoing as indicated.
The Clinical Supervisor will conduct biweekly clinical chart audits.
The Program and Division Directors will complete monthly clinical chart audits.
The CQI Manager and Deputy Director will complete quarterly quantitative and qualitative clinical chart reviews.
Any findings of these audits will be addressed with the clinician in a documented clinical supervision session, and corrected within 48 hours.
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709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records and the facility's policies and procedures, the facility failed to document a psychosocial evaluation within 5 days of admission, in five of seven applicable records reviewed.
Client # 3 was admitted on April 17, 2023 and was discharged on May 12, 2023. The record did not contain a psychosocial evaluation.
Client # 4 was admitted on June 7, 2023 and was discharged on July 7, 2023. The record did not contain a psychosocial evaluation.
Client # 5 was admitted on August 16, 2023 and was active at the time of the inspection. The record did not contain a psychosocial evaluation.
Client # 6 was admitted on August 17, 2023 and was active at the time of the inspection. The record did not contain a psychosocial evaluation.
Client # 8 was admitted on March 15, 2023 and was discharged on April 14, 2023. The record did not contain a psychosocial evaluation.
These finding were discussed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
Any missing documentation in active files will be completed no later than 10/20/23
On 8/17/23, the Deputy Director provided training to Counselors regarding Biopsychosocials.
The program was already implementing an internal remediation plan to correct clinical deficiencies noted through our internal CQI processes.
A new Clinical Supervisor was hired in September 2023. A new Program Director has been hired and will begin on 10/30/23.
All new staff will receive treatment planning training upon hire, and ongoing as indicated.
The Clinical Supervisor will conduct biweekly clinical chart audits.
The Program and Division Directors will complete monthly clinical chart audits.
The CQI Manager and Deputy Director will complete quarterly quantitative and qualitative clinical chart reviews.
Any findings of these audits will be addressed with the clinician in a documented clinical supervision session, and corrected within 48 hours.
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709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of eight client records, the facility failed to document treatment plan updates within the regulatory timeframe in one of one applicable record reviewed.
Client # 1 was admitted on January 18, 2023 and was discharged on March 20, 2023. The individual treatment and rehabilitation plan was completed on January 31, 2023, and the treatment plan update was due no later than March 2, 2023; however, the update was not completed prior to the client ' s discharge.
This is a repeat citation from the December 9, 2022 annual licensing renewal inspection.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
Any missing documentation in active files will be completed no later than 10/20/23
On 7/13/23, Counselors were trained on the treatment plan components by the Director of Quality Assurance, and on 8/17/23, the Deputy Director provided training to Counselors regarding treatment plan creation and time frames.
The program was already implementing an internal remediation plan to correct clinical deficiencies noted through our internal CQI processes.
A new Clinical Supervisor was hired in September 2023. A new Program Director has been hired and will begin on 10/30/23.
All new staff will receive treatment planning training upon hire, and ongoing as indicated.
The Clinical Supervisor will conduct biweekly clinical chart audits.
The Program and Division Directors will complete monthly clinical chart audits.
The CQI Manager and Deputy Director will complete quarterly quantitative and qualitative clinical chart reviews.
Any findings of these audits will be addressed with the clinician in a documented clinical supervision session, and corrected within 48 hours.
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709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plans in six of seven applicable records reviewed.
Client # 1 was admitted on January 18, 2023 and was discharged on March 20, 2023. The individual treatment and rehabilitation plan completed on January 31, 2023, indicated that the client was to receive one individual session per week; however, the record contained no documentation of an individual session between March 6, 2023 and the date of discharge.
Client # 3 was admitted on April 17, 2023 and was discharged on May 12, 2023. The individual treatment and rehabilitation plan completed on April 20, 2023, indicated that the client was to receive one individual session per week; however, the record contained no documentation of an individual session between April 29, 2023 and the date of discharge.
Client # 4 was admitted on June 7, 2023 and was discharged on July 7, 2023. The individual treatment and rehabilitation plan completed on June 12, 2023, indicated that the client was to receive one individual session per week; however, the record contained no documentation of individual sessions between June 8, 2023 and June 27, 2023, or between June 27, 2023 and the date of discharge.
Client # 5 was admitted on August 16, 2023 and was active at the time of the inspection. The individual treatment and rehabilitation plan completed on August 19, 2023, indicated that the client was to receive one individual session per week; however, the record contained no documentation of an individual session between August 17, 2023 and the date of the inspection.
Client # 7 was admitted on August 25, 2023 and was active at the time of the inspection. The individual treatment and rehabilitation plan completed on August 28, 2023, indicated that the client was to receive one individual session per week; however, the record contained no documentation of an individual session between August 29, 2023 and September 14, 2023.
Client # 8 was admitted on March 15, 2023 and was discharged on April 14, 2023. The individual treatment and rehabilitation plan completed on March 18, 2023, indicated that the client was to receive one individual session per week; however, the record contained no documentation of an individual session between March 15, 2023 and April 5, 2023.
This is a repeat citation from the December 9, 2022 and December 14, 2021 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
Any missing documentation in active files will be completed no later than 10/20/23
On 8/17/23, the Deputy Director provided training to Counselors regarding the delivery of services as indicated on the treatment plan.
The program was already implementing an internal remediation plan to correct clinical deficiencies noted through our internal CQI processes.
A new Clinical Supervisor was hired in September 2023. A new Program Director has been hired and will begin on 10/30/23.
On 7/13/23, Counselors were trained on the treatment plan components by the Director of Quality Assurance.
All new staff will receive treatment planning training upon hire, and ongoing as indicated.
The Clinical Supervisor will conduct biweekly clinical chart audits.
The Program and Division Directors will complete monthly clinical chart audits.
The CQI Manager and Deputy Director will complete quarterly quantitative and qualitative clinical chart reviews.
Any findings of these audits will be addressed with the clinician in a documented clinical supervision session, and corrected within 48 hours.
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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 ensure a complete client record included information relative to the client's involvement with the project, to include case consultation information within 15 days of admission, in four of seven applicable records reviewed.
Client # 3 was admitted on April 17, 2023 and was discharged on May 12, 2023. There was no documentation of case consultation information in the record.
Client # 5 was admitted on August 16, 2023 and was active at the time of the inspection. There was no documentation of case consultation information in the record.
Client # 7 was admitted on August 25, 2023 and was active at the time of the inspection. The case consultation information was not documented until September 13, 2023.
Client # 8 was admitted on March 15, 2023 and was discharged on April 14, 2023. There was no documentation of case consultation information in the record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
Any missing documentation in active files will be completed no later than 10/20/23
On 8/17/23, the Deputy Director provided training to Counselors regarding case consultations. Case consultations occur weekly on Wednesdays.
The program was already implementing an internal remediation plan to correct clinical deficiencies noted through our internal CQI processes.
A new Clinical Supervisor was hired in September 2023. A new Program Director has been hired and will begin on 10/30/23.
The Clinical Supervisor will conduct biweekly clinical chart audits.
The Program and Division Directors will complete monthly clinical chart audits.
The CQI Manager and Deputy Director will complete quarterly quantitative and qualitative clinical chart reviews.
Any findings of these audits will be addressed with the clinician in a documented clinical supervision session, and corrected within 48 hours.
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709.53(a)(9) LICENSURE Aftercare plans
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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record on an individual which includes information relative to the client's involvement with the project, including an aftercare plan, in two of three applicable records reviewed.
Client # 4 was admitted on June 7, 2023 and was discharged on July 7, 2023. The client record did not contain documentation of a completed aftercare plan.
Client # 8 was admitted on March 15, 2023 and was discharged on April 14, 2023. The client record did not contain documentation of a completed aftercare plan.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 8/17/23, the Deputy Director provided training to Counselors regarding required discharge documentation, including the Continuing Care Plan/Discharge Summary.
The program was already implementing an internal remediation plan to correct clinical deficiencies noted through our internal CQI processes.
A new Clinical Supervisor was hired in September 2023. A new Program Director has been hired and will begin on 10/30/23.
The Clinical Supervisor will conduct biweekly clinical chart audits.
The Program and Division Directors will complete monthly clinical chart audits.
The CQI Manager and Deputy Director will complete quarterly quantitative and |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record on an individual which includes information relative to the client's involvement with the project including a discharge summary, in four of five applicable records reviewed.
Client # 2 was admitted on May 4, 2023 and was discharged on May 9, 2023. The client record did not contain documentation of a completed discharge summary.
Client # 3 was admitted on April 17, 2023 and was discharged on May 12, 2023. The client record did not contain documentation of a completed discharge summary.
Client # 4 was admitted on June 7, 2023 and was discharged on July 7, 2023. The client record did not contain documentation of a completed discharge summary.
Client # 8 was admitted on March 15, 2023 and was discharged on April 14, 2023. The client record did not contain documentation of a completed discharge summary.
This is a repeat citation from the December 9, 2022 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
On 8/17/23, the Deputy Director provided training to Counselors regarding required discharge documentation, including the Continuing Care Plan/Discharge Summary.
The program was already implementing an internal remediation plan to correct clinical deficiencies noted through our internal CQI processes.
A new Clinical Supervisor was hired in September 2023. A new Program Director has been hired and will begin on 10/30/23.
The Clinical Supervisor will conduct biweekly clinical chart audits.
The Program and Division Directors will complete monthly clinical chart audits.
The CQI Manager and Deputy Director will complete quarterly quantitative and qualitative clinical chart reviews.
Any findings of these audits will be addressed with the clinician in a documented clinical supervision session, and corrected within 48 hours.
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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 ensure a complete client record included information relative to the client's involvement with the project, to include follow-up information, in two of three records reviewed.
Client # 2 was admitted on May 4, 2023 and was involuntarily discharged on May 9, 2023. The client record did not contain documentation of follow-up information.
Client # 3 was admitted on April 17, 2023 and was discharged on May 12, 2023. The client record did not contain documentation of follow-up information.
This is a repeat citation from the December 9, 2022 and December 14, 2021 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
The Division Director will conduct training regarding follow up documentation in the next staff meeting with the treatment team.
The program was already implementing an internal remediation plan to correct clinical deficiencies noted through our internal CQI processes.
A new Clinical Supervisor was hired in September 2023. A new Program Director has been hired and will begin on 10/30/23.
The Clinical Supervisor will conduct biweekly clinical chart audits.
The Program and Division Directors will complete monthly clinical chart audits.
The CQI Manager and Deputy Director will complete quarterly quantitative and qualitative clinical chart reviews.
Any findings of these audits will be addressed with the clinician in a documented clinical supervision session, and corrected within 48 hours.
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709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include verification that any work done by the client at the project is an integral part of his/her treatment and rehabilitation plan in four of seven applicable client records reviewed.
Client # 1 was admitted on January 18, 2023 and was discharged on March 20, 2023.
Client # 3 was admitted on April 17, 2023 and was discharged on May 12, 2023.
Client # 5 was admitted on August 16, 2023 and was active at the time of the inspection.
Client # 8 was admitted on March 15, 2023 and was discharged on April 14, 2023.
This is a repeat citation from the December 9, 2022 and December 14, 2021 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
Any missing documentation in active files will be completed no later than 10/20/23
The program was already implementing an internal remediation plan to correct clinical deficiencies noted through our internal CQI processes.
A new Clinical Supervisor was hired in September 2023. A new Program Director has been hired and will begin on 10/30/23.
On 7/13/23, Counselors were trained on the treatment plan components by the Director of Quality Assurance.
All new staff will receive treatment planning training upon hire, and ongoing as indicated.
The Clinical Supervisor will conduct biweekly clinical chart audits.
The Program and Division Directors will complete monthly clinical chart audits.
The CQI Manager and Deputy Director will complete quarterly quantitative and qualitative clinical chart reviews.
Any findings of these audits will be addressed with the clinician in a documented clinical supervision session, and corrected within 48 hours.
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709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records and a physical plant inspection, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for obtaining client signed consent to release information forms prior to disclosures of information was submitted and approved by the Department for the December 14, 2021 and December 9, 2022 annual licensing inspections. Obtaining client signed consent to release information forms prior to disclosing information was again found to be a deficiency in the September 18, 2023 licensing inspection.
A plan of correction for including follow-up information in the client record was submitted and approved by the Department for the December 14, 2021 and December 9, 2022 annual licensing inspections. Completing follow-up information was again found to be a deficiency in the September 18, 2023 licensing inspection.
A plan of correction for including verification of work therapy in the individual treatment and rehabilitation plan was submitted and approved by the Department for the December 14, 2021 and December 9, 2022 annual licensing inspections. Verification of work therapy on the individual treatment plans was again found to be a deficiency in the September 18, 2023 licensing inspection.
A plan of correction for providing services according to the treatment plan was submitted and approved by the Department for the December 14, 2021 and December 9, 2022 annual licensing inspections. Providing services according to the treatment plan was again found to be a deficiency in the September 18, 2023 licensing inspection.
A plan of correction for calling client emergency contacts within 12 hours of an Against Staff Advice discharge was submitted and approved by the Department for December 9, 2022 annual licensing inspection. Contacting emergency contacts was again found to be a deficiency in the September 18, 2023 licensing inspection.
A plan of correction for ensuring that heaters were permanently mounted was submitted and approved by the Department for December 9, 2022 annual licensing inspection. Space heaters that were not permanently mounted were again found to be a deficiency in the September 18, 2023 licensing inspection.
A plan of correction for ensuring emergency exits were not obstructed was submitted and approved by the Department for December 9, 2022 annual licensing inspection. Obstructed emergency exits was again found to be a deficiency in the September 18, 2023 licensing inspection.
A plan of correction for preparing alternate exit routes was submitted and approved by the Department for December 9, 2022 annual licensing inspection. Preparing alternate exit routes was again found to be a deficiency in the September 18, 2023 licensing inspection.
A plan of correction for updating treatment plans within the regulatory timeframe was submitted and approved by the Department for December 9, 2022 annual licensing inspection. Updating treatment plans was again found to be a deficiency in the September 18, 2023 licensing inspection.
A plan of correction for completing discharge summaries was submitted and approved by the Department for December 9, 2022 annual licensing inspection. Completing discharge summaries was again found to be a deficiency in the September 18, 2023 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will have ultimate responsibility for ensuring that all above-listed Corrective Action items are fully and correctly implemented.
The Division Director and Deputy Director will ensure through documented supervision sessions that the Program Director is aware of all requirements, and continues the ongoing process of implementing all corrective actions.
The newly-hired Program Director begins on 10/30/23. In the meantime, the Division Director will fulfill these responsibilities.
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