INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 29, 2022, 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. West Chester 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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705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on a physical plant inspection on June 29, 2022, the facility failed to ensure that garbage was stored in covered containers that prevent the penetration of insects and rodents as a trash receptacle outside of the kitchen was uncovered.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The garbage cans/dumpsters will be included on the environmental checklist which Recovery Support Professionals complete on each shift. This will be added no later than 7/31/22.
A weekly review of the log will be completed by the Program Director. Any issues identified will be immediately addressed with the submission of a maintenance order. The Program Director will follow up on any maintenance orders submitted to confirm status until it is completed.
The Division Director will complete a monthly review of all plans of correction items to ensure that they are fully implemented, and the Deputy Regional Director will complete quarterly reviews.
The Quality Assurance department will conduct at least quarterly reviews of the program, including all plan of correction items to ensure compliance.
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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 seven client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients in one of two applicable records reviewed.
Client #3 was admitted on March 14, 2022 and discharged Against Staff Advice (ASA) on April 27, 2022. The facility failed to follow their policy related to ASA discharges of calling the Emergency Contact within twelve hours.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
As of 7/14/22, all staff have received individual training in this area during documented clinical supervision sessions. At the end of each shift, the counselor will notify emergency contact for any client who left ASA during that shift.
This will be documented in the shift log in addition to completing a progress note in the client's chart.
Our upgraded Incident Reporting system provides a specific space to document whether the emergency contact was notified. This serves as another reminder to completed notification.
The Program Director will conduct a shift log review each day to ensure that no notifications were missed during that day and will follow up immediately with clinicians to make notification if any had been missed.
The Division Director will complete a monthly review of all plans of correction items to ensure that they are fully implemented, and the Deputy Regional Director will complete quarterly reviews.
The Quality Assurance department will conduct at least quarterly reviews of the program, including all plan of correction items to ensure compliance.
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709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a review of administrative documents submitted, the project failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
The project's last annual financial audit was for the years ending June 30, 2020 and 2019.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
Plan of Correction:
The Annual Financial Audit for the most recent fiscal year (FY 2020 ? 2021) was not completed in a timely manner due to delays on the part of the independent certified public accounting firm.
Among these delays were the application of new standards regarding the review of all leased properties (to include all real estate, business machines, and vehicles). This was a very laborious process that will not need to be repeated in the future.
Gaudenzia will obtain a completed financial audit from the independent certified public accounting firm on or before September 30th of 2022.
In order to help ensure that these delays do not occur in the future, the reorganized Fiscal department will begin preparation of all possible documents required for the audit as early as possible in the year.
Leadership in this department reviewed the regulations in DDAP 709.25 on 4/26/22 in order to ensure that all understand the importance of timely completion of the Financial Audit.
The Chief Financial Officer will oversee this process.
Target Date: 9/30/22
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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 seven client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in four records reviewed.
Client #2 was admitted on October 5, 2021 and was discharged on November 22, 2021. The record contained documentation of identifying information and lab work released to a diagnostic laboratory on October 6, 2021, to whom there was no client signed consent to release information form.
Client #4 was admitted on October 6, 2021 and was discharged on December 17, 2021. The record contained documentation of identifying information and lab work released to a diagnostic laboratory on October 17, 2021, to whom there was no client signed consent to release information form.
Client #5 was admitted on May 17, 2022 and was active at the time of the inspection. The record contained documentation of identifying information and lab work released to a diagnostic laboratory on June 29, 2022, to whom there was no client signed consent to release information form.
Client #6 was admitted on May 4, 2022 and was active at the time of the inspection. The record contained documentation of identifying information and lab work released to a diagnostic laboratory on May 4, 2022, to whom there was no client signed consent to release information form.
This is a repeat citation from the June 3, 2021 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 7/12/22 This has been corrected for all current clients who did not have this completed in their charts.
Going forward a specific release will be completed for all lab work.
On 7/1/22 the Program Director met with all staff to review this expectation, and these releases are now being completed for all clients.
The Program Director will complete at least bi-weekly audits of a sample of clinical charts using our Quantitative and Qualitative audit tools. Any incomplete or missing documentation will be brought to the attention of the staff member and corrected within 48 hours. This will be documented in a supervision note.
The Division Director will complete at least monthly audits of a sample of clinical charts using our Quantitative and Qualitative audit tools. Any issues noted will be brought to the attention of the Program Director to be addressed with staff as noted above.
The Quality Assurance department complete at least quarterly audits of a sample of clinical charts using our Quantitative and Qualitative audit tools. Any issues noted will be brought to the attention of the Deputy Regional Director and Program Director to be addressed with staff as noted above.
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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 seven 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 #1 was admitted on September 7, 2021 and was therapeutically discharged on October 20, 2021. 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
Going forward, this will be completed for all clients who are discharged involuntarily using the specific form for this purpose in our electronic health record.
The Program Director will meet with all clinical staff to review this expectation no later than 7/28/22.
This item was recently added to our Quantitative and Qualitative audit tools to ensure that this is monitored during all auditing as described below:
The Program Director will complete at least bi-weekly audits of a sample of clinical charts using our Quantitative and Qualitative audit tools. Any incomplete or missing documentation will be brought to the attention of the staff member and corrected within 48 hours. This will be documented in a supervision note.
The Division Director will complete at least monthly audits of a sample of clinical charts using our Quantitative and Qualitative audit tools. Any issues noted will be brought to the attention of the Program Director to be addressed with staff as noted above.
The Quality Assurance department complete at least quarterly audits of a sample of clinical charts using our Quantitative and Qualitative audit tools. Any issues noted will be brought to the attention of the Deputy Regional Director and Program Director to be addressed with staff as noted above.
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709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on the review of the unusual incident logbook, the project failed to file a written unusual incident report with the Department within three business days following an unusual incident involving the physical or sexual assault by staff or a client.
There was documentation of patient assaults on April 9, 2022 and May 23, 2022; however, there was no documentation that written unusual incident reports were filed with the Department.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Deputy Regional Director met with the Program Director on 7/14/22 to review this standard. The use of the DDAP ERS system was reviewed as well.
Our upgraded Incident Reporting system includes an email alert to the Program Director for any incident which may require notification to DDAP.
A binder will be maintained as an additional monitoring tool which will contain a checklist to ensure that all external reports are sent. The incident report in question was submitted on 8/2/2022.
A weekly review of this binder will be completed by the Program Director.
The Division Director will complete a monthly review of all plans of correction items to ensure that they are fully implemented, and the Deputy Regional Director will complete quarterly reviews.
The Quality Assurance department will conduct at least quarterly reviews of the program, including all plan of correction items to ensure compliance.
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709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on the review of the unusual incident logbook, the project failed to file a written unusual incident report with the Department within three business days following an unusual incident involving the presence of police, fire, or ambulance personnel.
There was documentation of the presence of ambulance personnel on March 3, 2022: however, there was no documentation that written unusual incident reports were filed with the Department.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Deputy Regional Director met with the Program Director on 7/14/22 to review this standard. The use of the DDAP ERS system was reviewed as well.
Our upgraded Incident Reporting system includes an email alert to the Program Director for any incident which may require notification to DDAP.
A binder will be maintained as an additional monitoring tool which will contain a checklist to ensure that all external reports are sent. The incident report in question was submitted on 8/2/2022.
A weekly review of this binder will be completed by the Program Director.
The Division Director will complete a monthly review of all plans of correction items to ensure that they are fully implemented, and the Deputy Regional Director will complete quarterly reviews.
The Quality Assurance department will conduct at least quarterly reviews of the program, including all plan of correction items to ensure compliance.
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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 four of seven records reviewed.
Client #1 was admitted on September 7, 2021 and was discharged on October 20, 2021. Treatment plans completed on September 10, 2021 and October 2, 2021, indicated that the client was to receive one individual session per week; however, the record contained no documentation of individual sessions between September 7, 2021 and September 28, 2021, or between September 28, 2021 and October 20, 2021.
Client #4 was admitted on October 6, 2021 and was discharged on December 17, 2021. Treatment plans completed on October 7, 2021 and November 12, 2021, indicated that the client was to receive one individual session per week; however, the record contained no documentation of individual sessions between October 7, 2021 and October 19, 2021, or between November 11, 2021 and December 7, 2021.
Client #5 was admitted on May 17, 2022 and was active at the time of the inspection. Treatment plans completed on May 19, 2022 and June 6, 2022, indicated that the client was to receive one individual session per week; however, the record contained no documentation of individual sessions from the date of admission to June 5, 2022, or between June 5, 2022 and June 22, 2022.
Client #7 was admitted on May 27, 2022 and was active at the time of the inspection. The treatment plan completed on June 5, 2022, indicated that the client was to receive one individual session per week; however, the record contained no documentation of individual sessions from May 31, 2022 through the date of the inspection.
This is a repeat citation from the June 3, 2021 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counselors are now to submit to the Program Director weekly confirmation of sessions having occurred for the week according to the Treatment Plan for each client.
On 7/11/22, the Program Director met with all clinical staff to review this expectation.
The Program Director will complete at least bi-weekly audits of a sample of clinical charts using our Quantitative and Qualitative audit tools. Any incomplete or missing documentation will be brought to the attention of the staff member and corrected within 48 hours. This will be documented in a supervision note.
The Division Director will complete at least monthly audits of a sample of clinical charts using our Quantitative and Qualitative audit tools. Any issues noted will be brought to the attention of the Program Director to be addressed with staff as noted above.
The Quality Assurance department complete at least quarterly audits of a sample of clinical charts using our Quantitative and Qualitative audit tools. Any issues noted will be brought to the attention of the Deputy Regional Director and Program Director to be addressed with staff as noted above.
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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 four of four applicable records reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Going forward, the Intake Specialist will contact clients who have been discharge within 7 days of their appointment for any referrals, or within 30 days for all other types of discharges, as appropriate.
As of 7/15/22, the Program Director met with the Intake Specialist to review this expectation, and the specific form utilized to document this contact in our electronic health record.
The Program Director will complete at least bi-weekly audits of a sample of clinical charts using our Quantitative and Qualitative audit tools. Any incomplete or missing documentation will be brought to the attention of the staff member and corrected within 48 hours. This will be documented in a supervision note.
The Division Director will complete at least monthly audits of a sample of clinical charts using our Quantitative and Qualitative audit tools. Any issues noted will be brought to the attention of the Program Director to be addressed with staff as noted above.
The Quality Assurance department complete at least quarterly audits of a sample of clinical charts using our Quantitative and Qualitative audit tools. Any issues noted will be brought to the attention of the Deputy Regional Director and Program Director to be addressed with staff as noted above.
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