INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 14, 2021 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel files, the facility to ensure that counselors met the educational and experiential qualifications in one of three applicable records.
Employee #4 was hired as a counselor by the facility on October 4, 2021. The employee does not possess the required degree with a major in a related field or licensure or certification to qualify as a counselor under the regulation.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #4 is no longer with the agency as of 12/17/21.
In the future, no candidate will begin work at the facility without a qualifying degree, or a plan in place to achieve such a degree in the case of a counselor assistant.
The Human Resources Specialist and the Program Director will review the requirements to ensure understanding and agreement. This will occur no later than 1/14/22.
Going forward, HR and Program Director will compare the qualifications of all candidates with the standards prior to any offer of employment. The Division Director will approve of all candidates before hire.
The Compliance department will conduct a review of all Plans of Correction within 9 months to ensure full implementation.
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of six personnel records, the facility failed to ensure that staff received at least six hours of HIV/AIDS training and four hours of TB/STD training in one record reviewed.
Employee # 5 was hired as a counselor on September 8, 2020 and has been in that position since. The employee was due to have the HIV/AIDS and TB/STD trainings no later than September 8, 2021. There was no documentation in the personnel file of the completion of the trainings as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All Inpatient staff will complete all required training within required timeframes, as delineated in 704.11.
Inpatient Director/Clinical Supervisor will ensure that all staff are scheduled for trainings prior to deadlines
The trainings of focus within the first year of employment will be: HIV/AIDS; TB/STD; Addictions 101; Confidentiality; Practical Application of Confidentiality Laws; and Regulations; Case Management Overview; Screening & Assessment;
These will be completed using a combination of internally-available trainings developed in collaboration with DDAP, and external trainings provided via BHTEN or other DDAP-approved resources.
Employee #5 will be scheduled to take the next available HIV/AIDS training and TB/STD training offered at Gaudenzia DRC on 1/28/22.
The Compliance department will conduct a review of all Plans of Correction within 9 months to ensure full implementation.
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705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
Based on a physical plant inspection on December 14, 2021, the facility failed to ensure that showers had slip-resistant surfaces in the Men ' s Unit shower stalls.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
There have been slip-resistant mats ordered for the Inpatient Men's Unit shower stalls.
Mats were ordered on the day of the inspection, 12/14/21, and installed on 12/21/21.
The Maintenance department conducts weekly walk-throughs to identify any physical plant issues, particularly any safety concerns. These are documented via the weekly Safety & Sanitation Report.
Program Director and Division Director will review the results of the walk-throughs each week, to ensure that any physical plant issues are identified and addressed.
The Quality Assurance department will conduct at least quarterly reviews to include physical plant inspections and reviews of the weekly Safety & Sanitation Reports, the findings of which will be discussed with the program, and action steps developed.
The Compliance department will conduct a review of all Plans of Correction within 9 months to ensure full implementation.
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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 December 14, 2021, the facility failed to ensure interior stairs were lit at all times.
The light on the 4th floor of the emergency exit from the Men ' s Unit was not lit.
The light between the 5th and 6th floors of the emergency exit from the Women ' s Unit was not lit.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The light bulbs in both stairwells were replaced on the day of the inspection, 12/14/21.
The Maintenance department conducts weekly walk-throughs to identify any physical plant issues, particularly any safety concerns. These are documented via the weekly Safety & Sanitation Report.
Program Director and Division Director will review the results of the walk-throughs each week, to ensure that any physical plant issues are identified and addressed.
The Quality Assurance department will conduct at least quarterly reviews to include physical plant inspections and reviews of the weekly Safety & Sanitation Reports, the findings of which will be discussed with the program, and action steps developed.
The Compliance department will conduct a review of all Plans of Correction within 9 months to ensure full implementation.
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705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of fire drill logs from February 2021 through October 2021, the failed to conduct fire drills during sleeping hours at least every six months.
Based on the program schedule provided by facility staff, the unit sleeping hours are 11:00 P.M. through 06:00 A.M. No fire drills between February 2021 and November 2021 were conducted between those hours.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Gaudenzia DRC Inpatient will conduct a Fire drill during sleeping hours (11PM ? 6AM) at least once every six months.
These drills will be documented on the Inpatient Fire Drill Log.
A Fire Drill was conducted on 12/28/21 at 11:15pm.
The Program Director and Division Director will review the Fire Drill Log each month to ensure that all are conducted according to DDAP 705.10 d 5 standards.
The Quality Assurance department will conduct at least quarterly reviews to include physical plant inspections and reviews of the Fire Drill Log, the findings of which will be discussed with the program, and action steps developed.
The Compliance department will conduct a review of all Plans of Correction within 9 months to ensure full implementation.
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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 client records, the facility failed to obtain a written informed and voluntary consent to release information form from the client for the disclosure of information contained in the client record in two of seven client records reviewed.
Client #1 was admitted on March 4, 2021 and was discharged June 2, 2021. There was evidence that the facility contacted an outside treatment provider, to whom the record contained no consent to release information form signed by the client.
Client #6 was admitted on October 30, 2021 and was an active client at the time of inspection. The record contained no consent to release information form to the funding source, however, there was evidence of billing.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Informed consents will be obtained for any information to be disclosed from the client record.
Client #6 - The Consent forms have been reviewed and signed by client and clinical staff, indicating the disclosure of information being authorized. The Consent form was entered into the Electronic Health Record on 12/27/21.
The consent form has been revised within our Electronic Health Record to ensure that it cannot be finalized until it is signed by the client and clinical staff, indicating the disclosure of information being authorized.
The Program Director will facilitate an in-service staff training on completing consent to release information forms at staff meeting on January 27, 2022
The Program Director/Clinical Supervisor will audit a sample of clinical charts at least monthly, to include a review of consent forms to ensure that all areas have been completed, including the required signatures. Any deficiencies noted will be addressed with specific clinicians in clinical supervision and corrections made within 3 days.
The Quality Assurance department will conduct at least quarterly reviews to include audits of clinical records, the findings of which will be discussed with the program, and action steps developed.
The Compliance department will conduct a review of all Plans of Correction within 9 months to ensure full implementation.
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709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of seven client records, the facility failed to ensure that consent to release information forms included the name of the person, agency, or organization to whom disclosure is made in one record reviewed.
Client #6 was admitted on October 30, 2021 and was an active client at the time of the inspection. The record contained eight consent to release information forms signed by the client on October 30, 2021 that were missing the name of the person, agency, or organization to whom disclosure is made.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Consents will be completed for all disclosures and include, but not be limited to: (1) Name of the person, agency or organization to whom disclosure is made.
Client #6 - The Consent forms were reviewed and signed by client and clinical staff, indicating the name of person, agency, or organization to whom disclosure was made. The Consent form was entered into the Electronic Health Record on 12/27/21.
The consent form has been revised within our Electronic Health Record to ensure that it cannot be finalized unless it addresses all required areas.
The Program Director will facilitate an in-service staff training on completing consent to release information forms at staff meeting on January 27, 2022
The Program Director/Clinical Supervisor will audit a sample of clinical charts at least monthly, to include a review of consent forms to ensure that all areas have been completed, including the name of the person, agency or organization to whom disclosure is made.
Any deficiencies noted will be addressed with specific clinicians in clinical supervision and corrections made within 3 days.
The Quality Assurance department will conduct at least quarterly reviews to include audits of clinical records, the findings of which will be discussed with the program, and action steps developed.
The Compliance department will conduct a review of all Plans of Correction within 9 months to ensure full implementation.
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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 seven client records, the facility failed to ensure that consent to release information forms included the specific information to be disclosed in one record reviewed.
Client #6 was admitted on October 30, 2021 and was an active client at the time of the inspection. The record contained eight consent to release information forms signed by the client on October 30, 2021 that were missing the specific information to be disclosed.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Consents will be completed for all disclosures and include the specific information to be disclosed.
Client #6 - The Consent forms were reviewed and signed by client and clinical staff, indicating the specific information to be disclosed. The Consent form was entered into the Electronic Health Record on 12/27/21.
The consent form has been revised within our Electronic Health Record to ensure that it cannot be finalized unless it addresses all required areas.
The Program Director will facilitate an in-service staff training on completing consent to release information forms at staff meeting on January 27, 2022
The Program Director/Clinical Supervisor will audit a sample of clinical charts at least monthly, to include a review of consent forms to ensure that all areas have been completed, including the specific information to be disclosed. Any deficiencies noted will be addressed with specific clinicians in clinical supervision and corrections made within 3 days.
The Quality Assurance department will conduct at least quarterly reviews to include audits of clinical records, the findings of which will be discussed with the program, and action steps developed.
The Compliance department will conduct a review of all Plans of Correction within 9 months to ensure full implementation.
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709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of seven client records, the facility failed to ensure that consent to release information forms included the purpose of disclosure in one record reviewed.
Client #6 was admitted on October 30, 2021 and was an active client at the time of the inspection. The record contained eight consent to release information forms signed by the client on October 30, 2021 that were missing the purpose of disclosure.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Consents will be completed for all disclosures and include the purpose of disclosure.
Client #6 - The Consent forms were reviewed and signed by client and clinical staff, indicating the purpose of disclosure. The Consent form was entered into the Electronic Health Record on 12/27/21.
The consent form has been revised within our Electronic Health Record to ensure that it cannot be finalized unless it addresses all required areas.
The Program Director will facilitate an in-service staff training on completing consent to release information forms at staff meeting on January 27, 2022
The Program Director/Clinical Supervisor will audit a sample of clinical charts at least monthly, to include a review of consent forms to ensure that all areas have been completed, including the purpose of disclosure. Any deficiencies noted will be addressed with specific clinicians in clinical supervision and corrections made within 3 days.
The Quality Assurance department will conduct at least quarterly reviews to include audits of clinical records, the findings of which will be discussed with the program, and action steps developed.
The Compliance department will conduct a review of all Plans of Correction within 9 months to ensure full implementation.
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709.28 (c) (5) 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:
(5) Dated signature of witness.
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Observations
Based on a review of seven client records, the facility failed to ensure that consent to release information forms included the dated signature of a witness in one record reviewed.
Client #6 was admitted on October 30, 2021 and was an active client at the time of the inspection. The record contained eight consent to release information forms signed by the client on October 30, 2021 that were missing the dated signature of a witness.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Informed consents will include dated signature of witness.
Client #6 - The Consent forms have been reviewed and signed by client and clinical staff, including the dated signature of witness. The Consent form was entered into the Electronic Health Record on 12/27/21.
The consent form has been revised within our Electronic Health Record to ensure that it cannot be finalized until it is signed by the client and clinical staff, including the dated signature of witness.
The Program Director will facilitate an in-service staff training on completing consent to release information forms at staff meeting on January 27, 2022
The Program Director/Clinical Supervisor will audit a sample of clinical charts at least monthly, to include a review of consent forms to ensure that all areas have been completed, including the dated signature of witness. Any deficiencies noted will be addressed with specific clinicians in clinical supervision and corrections made within 3 days.
The Quality Assurance department will conduct at least quarterly reviews to include audits of clinical records, the findings of which will be discussed with the program, and action steps developed.
The Compliance department will conduct a review of all Plans of Correction within 9 months to ensure full implementation.
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709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of seven client records, the facility failed to ensure that consent to release information forms included the date, event, or condition upon which the consent will expire in one record reviewed.
Client #6 was admitted on October 30, 2021 and was an active client at the time of the inspection. The record contained eight consent to release information forms signed by the client on October 30, 2021 that were missing the date, event, or condition upon which the consent will expire.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Informed consents will include date, event or condition upon which the consent will expire.
Client #6 - The Consent forms have been reviewed and signed by client and clinical staff, including the date, event or condition upon which the consent will expire. The Consent form was entered into the Electronic Health Record on 12/27/21.
The consent form has been revised within our Electronic Health Record to ensure that it cannot be finalized until it is signed by the client and clinical staff, including the date, event or condition upon which the consent will expire.
The Program Director will facilitate an in-service staff training on completing consent to release information forms at staff meeting on January 27, 2022
The Program Director/Clinical Supervisor will audit a sample of clinical charts at least monthly, to include a review of consent forms to ensure that all areas have been completed, including the date, event or condition upon which the consent will expire. Any deficiencies noted will be addressed with specific clinicians in clinical supervision and corrections made within 3 days.
The Quality Assurance department will conduct at least quarterly reviews to include audits of clinical records, the findings of which will be discussed with the program, and action steps developed.
The Compliance department will conduct a review of all Plans of Correction within 9 months to ensure full implementation.
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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 seven client records, the facility failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plans in four records reviewed.
Client #1 was admitted on March 4, 2021 and was discharged on June 2, 2021. The treatment plan update completed on May 3, 2021 indicated the frequency of individual sessions to be weekly; however, no individual sessions were held between May 10, 2021 and June 2, 2021.
Client #4 was admitted on November 2, 2021 and was discharged on December 1, 2021. The comprehensive treatment plan completed on November 4, 2021 indicated the frequency of individual sessions to be weekly; however, no individual sessions were held between November 13, 2021 and November 30, 2021.
Client #5 was admitted on November 18, 2021 and was an active client at the time of the inspection. The comprehensive treatment plan completed on November 23, 2021 indicated the frequency of individual sessions to be weekly; however, no individual sessions were held between November 23, 2021 and December 10, 2021.
Client #7 was admitted on November 11, 2021 and was an active client at the time of the inspection. The preliminary treatment plan completed on November 12, 2021 indicated the frequency of individual sessions to be weekly; however, no individual sessions were held between November 12, 2021 and December 1, 2021, or between December 3, 2021 and December 14, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counseling services will be provided according to the treatment plan.
Delivery of counseling services will be documented in the client record.
The Inpatient Program Director will facilitate an in-service staff training on treatment plan adherence and documentation of individual counseling sessions on 1/27/22.
The Program Director/Clinical Supervisor will audit a sample of clinical charts at least monthly, to include a review of treatment plans and session notes. Any deficiencies noted will be addressed with specific clinicians in clinical supervision and corrections made within 3 days.
The Quality Assurance department will conduct at least quarterly reviews to include audits of clinical records, the findings of which will be discussed with the program, and action steps developed.
The Compliance department will conduct a review of all Plans of Correction within 9 months to ensure full implementation.
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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 one of two applicable records reviewed.
Client #1 was admitted on March 4, 2021 and was discharged on June 2, 2021. The client record did not contain documentation of follow-up information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clients will be contacted post-discharge to obtain follow-up information.
Follow up information shall be obtained for each client post-discharge. If there is difficulty contacting the client, there will be documentation of each follow up attempt using the Follow-Up Contact Note in the electronic health record.
Primary Counselors and/or designee of the Program/Clinical Supervisor or Director shall assume responsibility for client follow-up.
The Inpatient Program Director will facilitate an in-service staff training on to include discussion of follow-up requirements on January 27, 2022
The Program Director/Clinical Supervisor will audit a sample of clinical charts at least monthly, to include a review of follow-up documentation.
The Quality Assurance department will conduct at least quarterly reviews to include audits of clinical records, the findings of which will be discussed with the program, and action steps developed.
The Compliance department will conduct a review of all Plans of Correction within 9 months to ensure full implementation.
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