INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on April 9, 2024, 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. 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of personnel records, the facility failed to ensure that annual written individual staff performance evaluations, were reviewed and signed by the employee per the facility ' s policy and procedure manual in two out of four personnel records reviewed. The facility ' s policy and procedure manual states that the annual job performance evaluations are due at the beginning of each calendar year. Project staff indicated evaluations specifically are to be completed and signed by February 1 each year.
Employee #1 was hired on September 9, 2019 as the project director and is still in that position at the time of the inspection The annual work performance evaluation was not completed until February 28, 2024.
Employee #4 was hired on April 18, 2022 as a counselor and was still in that position at the time of the inspection. The annual work performance was not competed until February 20, 2024.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
By May 10, 2024, Division Director will speak to the Clinical Supervisors at all programs to let them know the expectation is to review the annual reviews with all staff one week prior to 1/31/25. The Division Director will further review the expectation is after they are discussed with the staff, to have the staff immediately sign into their ADP to sign off on their review and write any applicable comments. |
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.
|
Observations
Based on the review of client records, the facility failed to document case consultations within the timeframe established by the facility ' s policy and procedure manual in five out of six applicable client records. The facility's policy and procedure manual states case consultations are completed every ninety days unless the client ' s treatment is less than ninety then one is completed.
Client #1 was admitted on October 26, 2023 and was still active at the time of the inspection. A case consultation was due no later than January 26, 2024; however, there is no documentation that one was completed.
Client #2 was admitted on August 31, 2023 and was still active at the time of the inspection. A case consultation was due no later than December 1, 2023; however, there is no documentation that one was completed.
Client #3 was admitted on December 29, 2023 and was still active at the time of the inspection. A case consultation was due no later than March 29, 2024; however, there is no documentation that one was completed.
Client #5 was admitted on November 15, 2023 and was discharged on January 12, 2024. A case consultation was to be completed prior to discharge if the client was only in treatment less than 90 days, there is no documentation that one was completed.
Client #7 was admitted on December 28, 2023 and was discharged on February 26, 2024. A case consultation was to be completed prior to discharge if the client was only in treatment less than 90 days, there is no documentation that one was completed.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Beginning May 3, 2024, the Clinical Supervisor will run the Clinical Forms Audit report monthly and send out emails to all staff of case consultations coming due. The Clinical Supervisor will ensure that these case consults are completed by doing monthly chart audits. Both the Division Director and Outpatient Director will do quarterly chart audits to ensure that this is completed |
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.
|
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 two of four applicable records. The facility ' s policy and procedure manual states that a discharge summary is completed within seven days of discharge.
Client #5 was admitted November 15, 2023 and was discharged on January 12, 2024 A discharge summary was due no later than January 19, 2024; however, there is no documentation that one was completed.
Client #7 was admitted on December 28, 2023 and was discharged on February 26, 2024. A discharge summary was due no later than March 4, 2024; however, there is no documentation that one was completed.
This is a repeat citation from the June 21, 2023 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Starting May 10, 2024 Clinical Supervisor will run the discharge analysis report weekly and send emails to counselors of outstanding discharge paperwork. After the staff meeting on May 10th, counselors will be given one hour of paperwork time dedicated to discharge paperwork per week that must be completed. The Clinical Supervisor will do monthly chart audits and will do both active and discharged clients to ensure this is being followed. |