INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 28, 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 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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709.25 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
The Annual Financial Audit for the most recent fiscal year (FY 2020 ? 2021) was not completed in a timely manner due to the 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
Completion date: 9/30/2022
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709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on the review of client records on March 28, 2022, the project failed to obtain written acknowledgement that the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion in three of fourteen client records reviewed.
Client #8 was admitted on November 10, 2021 and was current at the time of the inspection. There was no documentation of written acknowledgement in the client record.
Client #9 was admitted on December 7, 2021 and was current at the time of the inspection. There was no documentation of written acknowledgement in the client record.
Client #13 was admitted on July 8, 2021 and was discharged on December 13, 2021. There was no documentation of written acknowledgement in the client record.
The findings were discussed with project staff during the licensing process.
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Plan of Correction
In December of 2021 Gaudenzia rolled out a new Gaudenzia Consents sign off which does include acknowledgment of orientation and receipt of client handbook in which client rights are included. Moving forward the Clinical Supervisor will conduct routine monthly audits to include the Gaudenzia Consents sign off form to ensure compliance. |
709.82(a)(2) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on the review of seven client records on March 28, 2022, the facility failed to document type and/or frequency of treatment and rehabilitation services in six out of seven applicable records reviewed.
Client #2 was admitted on March 8, 2022 and was still active at the time of the inspection. The initial treatment plan dated March 8, 2022 did not have type and frequency of treatment and rehabilitation services documented.
Client #3 was admitted on March 9, 2022 and was still active at the time of the inspection. The initial treatment plan dated March 9, 2022 did not have type and frequency of treatment and rehabilitation services documented.
Client #4 was admitted on March 8, 2022 and was still active at the time of the inspection. The initial treatment plan and comprehensive treatment plans dated; March 8, 2022 and March 14, 2022 did not have type and frequency of treatment and rehabilitation services documented.
Client #5 was admitted on October 20, 2021 and was discharged on November 23, 2021. The initial treatment plan and comprehensive treatment plans dated; October 20, 2021 and October 27, 2021 did not have frequency of treatment and rehabilitation services documented.
Client #6 was admitted on October 28, 2021 and was discharged on December 7, 2021. The initial treatment plan dated November 5, 2021 did not have frequency of treatment and rehabilitation services documented.
Client #7 was admitted on January 18, 2022 and was discharged on February 24, 2022. The initial and comprehensive treatment plans dated January 18, 2022 and January 28, 2022, did not have frequency of treatment and rehabilitation services documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor engaged in a training with the clinical team on 4/08/22 in which he reviewed the proper documentation of time and frequency on the initial tx plans with the team. Clinical Supervisor will conduct training on 4/29/22 with the team to ensure they are aware this is to be included on all tx plans, and not just initial. Counselors now know how to properly document both time and frequency in the EHR system using a different format that allows them to do so. Clinical Supervisor will continue to complete monthly chart audits of each counselors charts to ensure compliance. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of seven client records on March 28, 2022, the facility failed to provide individual counseling at least twice weekly in seven out of seven applicable records reviewed.
Client #1 was admitted on March 3, 2022 and was current at the time of the inspection. Client #1 only had documented individual therapy sessions on March 7, 2022, March 14, 2022 and March 25, 2022.
Client #2 was admitted on March 8, 2022 and was current at the time of the inspection. Client #2 only had a documented individual therapy session on March 8, 2022.
Client #3 was admitted on March 9, 2022 and was current at the time of the inspection. Client #3 had no documented individual therapy sessions.
Client #4 was admitted on March 8, 2022 and was current at the time of the inspection. Client #4 had no documented individual therapy sessions.
Client #5 was admitted on October 20, 2021 and was discharged on November 23, 2021. Client #5 only had documented individual therapy sessions on October 27, 2021, November 5, 2021 and November 17, 2021.
Client #6 was admitted on October 28, 2021 and was discharged on December 7, 2021. Client #6 only had documented individual therapy sessions on November 10, 2021, November 17, 2021 and November 24, 2021.
Client #7 was admitted on January 18, 2022 and was discharged on February 24, 2022. Client #7 only had documented individual therapy sessions on January 28, 2022 and February 14, 2022.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
In March of 2022 the program added two additional support counselors into our Partial Hospitalization Program to ensure that the primary PHP counselors would be able to complete the required two individual sessions per week with each of our PHP clients. Clinical Supervisor will ensure that these are being completed and documented accordingly through monthly chart audits and weekly supervision sessions with the PHP counselors. |
709.83(a)(6) LICENSURE Client records
709.83. 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:
(6) Aftercare plans, if applicable.
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Observations
Based on a review of client records on March 28, 2022, the project failed to include aftercare plans in two out of three applicable records reviewed.
Client #5 was admitted on October 20, 2021 and was discharged on November 23, 2021. There was no documentation of an aftercare plan in the client record.
Client #6 was admitted on October 28, 2021 and was discharged on December 7, 2021. There was no documentation of an aftercare plan in the client record.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Clinical Supervisor will complete both open and closed chart audits on a monthly basis with each member of the clinical team to ensure that Aftercare Plans are being completed. Upcoming Discharges will be reviewed with each counselor during weekly supervision sessions by Clinical Supervisor to ensure that Aftercare Plans are being completed. Documentation and proper Aftercare planning strategies were reviewed with the clinical team during clinical team meeting on 4/01/22 by Clinical Supervisor. |
709.83(a)(10) LICENSURE Client records
709.83. 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 on March 28, 2022, the project failed to include a discharge summary in two out of three applicable records reviewed.
Client #5 was admitted on October 20, 2021 and was discharged on November 23, 2021. There was no documentation of a discharge summary in the client record.
Client #6 was admitted on October 28, 2021 and was discharged on December 7, 2021. There was no documentation of a discharge summary in the client record.
These findings were reviewed with project staff during the licensing process.
This was a repeat citation from the May 27, 2021 licensing inspection.
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Plan of Correction
Clinical Supervisor will complete both open and closed chart audits on a monthly basis with each member of the clinical team to ensure that Discharge Summaries are being completed. Recent Discharges will be reviewed with each counselor during weekly supervision sessions by Clinical Supervisor to ensure that Discharge Summaries are being completed. Documentation of Discharge Summaries were reviewed with the clinical team during clinical team meeting on 4/01/22 by Clinical Supervisor. |
709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
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Observations
Based on the review of client records on March 28, 2022, the facility failed to document client orientation to project policies in three out of seven applicable records reviewed.
Client #8 that was admitted on December 21, 2021 and was current at the time of the inspection. There was no documentation in the client record that the client was oriented to the project policies.
Client #12 that was admitted on August 3, 2021 and was discharged on November 29, 2021. There was no documentation in the client record that the client was oriented to the project policies.
Client #13 that was admitted on July 8, 2021 and was discharged on December 13, 2021. There was no documentation in the client record that the client was oriented to the project policies.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In December of 2021 Gaudenzia rolled out a new stream lined Gaudenzia Consents sign off which does include acknowledgment of orientation and receipt of client handbook in which project policies are included. Client signature indicates they received their orientation materials (handbook, etc). Moving forward the Clinical Supervisor will add the Gaudenzia Consent sign off as part of his routine monthly audits to ensure compliance. |
709.91(b)(2)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(ii) Hours of operation.
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Observations
Based on the review of client records on March 28, 2022, the facility failed to document client orientation to hours of operation in three out of seven applicable records reviewed.
Client #8 that was admitted on December 21, 2021 and was current at the time of the inspection. There was no documentation in the client record that the client was oriented to the hours of operation.
Client #12 that was admitted on August 3, 2021 and was discharged on November 29, 2021. There was no documentation in the client record that the client was oriented to the hours of operation.
Client #13 that was admitted on July 8, 2021 and was discharged on December 13, 2021. There was no documentation in the client record that the client was oriented to the hours of operation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In December of 2021 Gaudenzia rolled out a new stream lined Gaudenzia Consents sign off which does include acknowledgment of orientation and receipt of client handbook in which hours of operation are included. Client signature indicates they received their orientation materials (handbook, etc). Moving forward the Clinical Supervisor will add the Gaudenzia Consents sign off as part of the routine monthly audit of charts to ensure compliance. |
709.91(b)(2)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iii) Fee schedule.
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Observations
Based on the review of client records on March 28, 2022, the facility failed to document client orientation to the fee schedule in three out of seven applicable records reviewed.
Client #8 that was admitted on December 21, 2021 and was current at the time of the inspection. There was no documentation in the client record that the client was oriented to the facility fee scale.
Client #12 that was admitted on August 3, 2021 and was discharged on November 29, 2021. There was no documentation in the client record that the client was oriented to the facility fee scale.
Client #13 that was admitted on July 8, 2021 and was discharged on December 13, 2021. There was no documentation in the client record that the client was oriented to the facility fee scale.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In December of 2021 Gaudenzia rolled out a new stream lined Gaudenzia Consents sign off which does include acknowledgment of orientation and receipt of client handbook in which the fee schedules are included. Client signature indicates they received their orientation materials (handbook, etc). Moving forward the Clinical Supervisor will add the Gaudenzia Consents sign off to the routine monthly audit of client charts to ensure compliance. |
709.91(b)(2)(iv) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iv) Services provided.
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Observations
Based on the review of client records on March 28, 2022, the facility failed to document client orientation to include a familiarization with the services provided in three out of seven applicable records reviewed.
Client #8 that was admitted on December 21, 2021 and was current at the time of the inspection. There was no documentation in the client record that the client orientation included a familiarization with the services provided.
Client #12 that was admitted on August 3, 2021 and was discharged on November 29, 2021. There was no documentation in the client record that the client orientation included a familiarization with the services provided.
Client #13 that was admitted on July 8, 2021 and was discharged on December 13, 2021. There was no documentation in the client record that the client orientation included a familiarization with the services provided.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In December of 2021 Gaudenzia rolled out a new stream lined Gaudenzia Consents sign off which does include acknowledgment of orientation and receipt of client handbook in which types of services provided are included. Client signature indicates they received their orientation materials (handbook, etc). Moving forward the Clinical Supervisor will add the Gaudenzia Consent sign off as part of routine monthly chart audits to ensure compliance. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on the review of seven client records on March 28, 2022, the facility failed to document type and/or frequency of treatment and rehabilitation services in three out of seven applicable records reviewed.
Client #11 was admitted on November 29, 2021 and was still active at the time of the inspection. The initial treatment plan dated November 29, 2021 did not have type and frequency of treatment and rehabilitation services documented.
Client #12 was admitted on August 3, 2021 and was discharged on November 29, 2021. The initial treatment plan dated August 3, 2021 and comprehensive treatment plan dated September 1, 2021 did not have type and frequency of treatment and rehabilitation services documented.
Client #14 was admitted on June 22, 2021 and was discharged on December 22, 2021. The initial treatment plan dated June 22, 2021 did not have type and frequency of treatment and rehabilitation services documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor engaged in a training with the clinical team on 4/08/22 in which he reviewed the proper documentation of type and frequency on the initial tx plans with the team. Clinical Supervisor will conduct training with clinical team to ensure that this is being completed on all tx plans, not just initial. Counselors now know how to properly document both type and frequency in the EHR system using a different format that allows them to do so. Clinical Supervisor will continue to complete monthly chart audits of each counselors charts to ensure compliance. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records on March 28, 2022, the facility failed to document treatment plan updates within the regulatory timeframe in six out of seven client records reviewed.
Client #8 was admitted on November 10, 2021 and was current at the time of the inspection. A treatment plan update was completed on December 1, 2021, and the next update was due by February 1, 2022; however, the next treatment plan was not completed until March 4, 2022.
Client #9 was admitted on December 7, 2021 and was current at the time of the inspection. A treatment plan update was completed on January 27, 2022, and the next update was due by March 27, 2022; however, there was not one documented at the time of the inspection.
Client #11 was admitted on November 29, 2021 and was current at the time of the inspection. A treatment plan update was completed on January 4, 2022, and the next update was due by March 4, 2022; however, there was not one documented at the time of the inspection.
Client #12 was admitted on August 3, 2021 and was discharged on November 29, 2021. A treatment plan update was completed on September 1, 2021, and the next update was due by November 1, 2021; however, there was not one documented at the time of the inspection.
Client #13 was admitted on July 8, 2021 and was discharged on December 13, 2021. A treatment plan update was completed on September 28, 2021, and the next update was due by November 28, 2021; however, there was not one documented at the time of the inspection.
Client #14 was admitted on June 22, 2021 and was discharged on December 22, 2021. An initial treatment plan was completed on June 22, 2021, and the next update was due by August 22, 2021; however, there was not one completed until September 30, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor conducted an in service training with the clinical team on 4/01/22 in which time frames for tx plan completions were reviewed. Clinical Supervisor will conduct monthly chart audits on each member of the clinical team to ensure these are being completed within the required time frame. These chart audits will be reviewed with each counselor during weekly supervision sessions. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records on March 28, 2022, the project failed to include aftercare plans in one out of three applicable records reviewed.
Client #13 was admitted on July 8, 2021 and was discharged on December 13, 2021. There was no documentation of an aftercare plan in the client record.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Clinical Supervisor will complete both open and closed chart audits on a monthly basis with each member of the clinical team to ensure that Aftercare Plans are being completed. Upcoming Discharges will be reviewed with each counselor during weekly supervision sessions by Clinical Supervisor to ensure that Aftercare Plans are being completed. Documentation and proper Aftercare planning strategies were reviewed with the clinical team during clinical team meeting on 4/01/22 by Clinical Supervisor. |
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 on March 28, 2022, the project failed to include a discharge summary in one out of three applicable records reviewed.
Client #13 was admitted on July 8, 2021 and was discharged on December 13, 2021. There was no documentation of a discharge summary in the client record.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Clinical Supervisor will complete both open and closed chart audits on a monthly basis with each member of the clinical team to ensure that Discharge Summaries are being completed. Recent Discharges will be reviewed with each counselor during weekly supervision sessions by Clinical Supervisor to ensure that Discharge Summaries are being completed. Documentation of Discharge Summaries were reviewed with the clinical team during clinical team meeting on 4/01/22 by Clinical Supervisor. |