INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 11, 2025, 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. Fulton County Outpatient 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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709.28 (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 an informed and voluntary consent from the client for the disclosure of information contained in the client record in two out of seven records reviewed.
Client #2 was admitted on January 2, 2025 and was still active at the time of the inspection. There was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the insurance was billed for the services.
Client #4 was admitted on March 20, 2024 and discharged on September 19, 2024. There was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the insurance was billed for the services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor to review in staff meeting on 4/1/2025 that part of the initial appointment is to obtain releases for funding.
Clinical Supervisor will continue to perform monthly chart audits that includes review of required releases. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on the review of client records, the facility failed to document case consultations within the facility ' s policy and procedures manual timeframe in five out of five applicable records. The facility's policy and procedures manual states that case consults are due every ninety days.
Client #1 was admitted on September 24, 2024 and was still active at the time of the inspection. A case consultation was due no later than December 24, 2024; however, there is no documentation that one was completed.
Client #4 was admitted on March 20, 2024 and discharged on September 19, 2024. A case consultation was due no later than June 20, 2024; however, one was not completed until August 13, 2024.
Client #5 was admitted on August 14, 2024 and discharged on January 7, 2025. A case consultation was due no later than November 14, 2024; however, there is no documentation that one was completed.
Client #6 was admitted on admitted on June 24, 2024 and discharged on February 26, 2025. A case consultation was completed on September 18, 2024, and the next one was due no later than December 18, 2024; however, there is not documentation that one was completed.
Client #7 was admitted on June 26, 2024 and discharged on January 14, 2025. A case consultation was completed on September 18, 2024, and the next one was due no later than December 18, 2024; however, there is no documentation that one was completed.
This is a repeat citation from the April 24, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will review current OP workflows during clinical meeting on April 1st, 2025.
Clinical Supervisor will continue to complete monthly chart audits that includes monitoring of case consultations. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to provide 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 out of four applicable records. The facility's policy and procedure manual states that a discharge summary is completed within seven days of discharge.
Client #4 was admitted March 20, 2024 and discharged on September 19, 2024. A discharge summary was due no later than September 26, 2024; however, there is no documentation that one was completed.
Client #5 was admitted on August 14, 2024 and discharged on January 7, 2025. A discharge summary was due no later than January 14, 2025; however, there is no documentation that one was completed.
Client #6 was admitted on June 24, 2024 and discharged on February 26, 2025. A discharge summary was due no later than March 5, 2025; however, there is no documentation that one was completed.
Client #7 was admitted on June 26, 2024 and discharged on January 14, 2025. A discharge summary was due no later than January 21, 2025; however, there is no documentation that one was completed.
This is a repeat citation from the April 24, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During clinical meeting on April 1st, 2025, Clinical Supervisor will advise clinical staff to block off time in their schedule each week to focus on completing discharge paperwork.
Clinical supervisor will monitor adherence to completion of discharge summaries by auditing 10% of all closed charts for that month. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include follow-up information in one out of three applicable discharged records reviewed.
Client #4 was admitted on March 20, 2024 and was discharged on September 19, 2024. A follow up contact was due no later than October 19, 2024; per facility policy that one be completed within 30 days unless there is an aftercare appointment then within 7 days of the appointment, however, there is no documentation that one was completed.
This is a repeat citation from the April 27, 2022, June 3, 2023, and April 24, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During clinical meeting on April 1st, 2025, Clinical Supervisor will advise clinical staff to block off time in their schedule each week to focus on completing discharge paperwork, which will include reviewing timelines of when a follow up contact note is due.
Clinical supervisor will monitor adherence of the follow up contact note being completed by auditing 10% of all closed charts for that month.
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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, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for completing and documenting follow-up information for the outpatient records was submitted and approved by the Department for the April 27, 2022, June 3, 2023, and April 24, 2024 annual licensing inspections. Completing and documenting follow-up information was again found to be a deficiency in the March 11, 2025 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning April 8th, 2025 and occurring on a monthly basis, the Division Director will participate in a scheduled Clinical Meeting for this location. The Division Director will review the current POCs that are in place with the staff and also review the chart audits for the current month. This will allow the Division Director to follow through on current POCs. Any deficiencies will be reviewed with Clinical Supervisor the same day of the meeting and follow up with documentation will be requested. This will continue throughout the year. |