INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on August 13, 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
|
709.82(c) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
|
Observations
Based on a review of client records, the facility failed to ensure the clients received counseling services according to their individual treatment plan in two of two applicable records.
Client #8 was admitted to partial hospitalization on July 30, 2024 and still a current client. The treatment plan dated July 30, 2024 indicated five days of group therapy per week and two days of individual sessions per week. There was no documentation of the client receiving any sessions since intake.
Client #9 was admitted to partial hospitalization on July 31, 2024 and still a current client. The treatment plan dated July 31, 2024 indicated five days of group therapy per week and two days of individual sessions per week. There was no documentation of the client receiving any sessions since intake.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
Clinical Director will review documentation standards in regard to progress notes and documenting missed visits by 10/1/2024. All notes will be completed within 72 hours of the provided service. All missed visits will be documented with the note to chart function or status update. The record of service report will be run by the Clinical Director weekly and any deficiencies will be sent to the counselor to review. Counselor will complete necessary notes within 48 hours. |
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.
|
Observations
Based on a review of client records, the facility failed to assure partial hospitalization clients are provided individual counseling services at least twice a week in two of two client records.
Client #8 was admitted to partial hospitalization on July 30, 2024 and still a current client. The client record did not include any indication that client has attended any individual sessions since intake. Facility staff indicated that client has been attending sessions but were unable to confirm dates of individual sessions attended.
Client #9 was admitted to partial hospitalization on July 31, 2024 and still a current client. The client record did not include any indication that client has attended any individual sessions since intake. Facility staff indicated that client has been attending sessions but were unable to confirm dates of individual sessions attended.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
Clinical Director will review partial schedule requirements by 10/1/2024. Individual session will be conducted twice per week. All individual session notes will be completed within 72 hours of the provided service. All missed visits will be documented with the note to chart function or status update. The record of service report will be run by the Clinical Director weekly to ensure services are taking place and any deficiencies will be sent to the counselor to review. Counselor will address any deficiencies within 48 hours. |
709.82(d)(2) 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:
(2) Group counseling, at least twice weekly.
|
Observations
Based on a review of client records, the facility failed to assure partial hospitalization clients are provided group counseling services at least twice a week in two of two client records.
Client #8 was admitted to partial hospitalization on July 30, 2024 and still a current client. The client record did not include any indication that client has attended any group sessions since intake. Facility staff indicated that client has been attending sessions but were unable to confirm dates of group sessions attended.
Client #9 was admitted to partial hospitalization on July 31, 2024 and still a current client. The client record did not include any indication that client has attended any group sessions since intake. Facility staff indicated that client has been attending sessions but were unable to confirm dates of group sessions attended.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
Clinical Director will review partial schedule requirements by 10/1/2024. Group Counseling sessions will be conducted as scheduled, at least twice per week. All group session notes will be completed within 72 hours of the provided service. All missed visits will be documented with the note to chart function or status update. The record of service report will be run by the Clinical Director weekly to ensure services are taking place and any deficiencies will be sent to the counselor to review. Counselor will address any deficiencies within 48 hours. |
709.83(a)(9) 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:
(9) Progress notes.
|
Observations
Based on a review of client records, the facility failed to ensure client records included progress notes for services received in the partial hospitalization level of care in two of two records reviewed.
According to facility policy and procedure manual, progress notes should be entered into clients ' electronic medical records no later than 72 hours after conclusion of services.
Client #8 was admitted to partial hospitalization on July 30, 2024 and still a current client. No progress notes were found in the client record. Staff confirmed client has been attending partial hospitalization sessions.
Client #9 was admitted to partial hospitalization on July 31, 2024 and still a current client. One progress note has been found on July 31, 2024 for intake documentation. No other progress notes have been found in the client record. Staff confirmed client has been attending partial hospitalization sessions since August 5, 2024.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
Clinical Director will review documentation standards in regard to progress notes and documenting missed visits by 10/1/2024. All notes will be completed within 72 hours of the provided service. All missed visits will be documented with the note to chart function or status update. The record of service report will be run by the Clinical Director weekly and any deficiencies will be sent to the counselor to review. Counselor will complete necessary notes within 48 hours. |
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.
|
Observations
Based on a review of client records, the facility failed to review and update treatment and rehabilitation plans within 60 days in five of seven client records.
Client #1 was admitted on January 31, 2024 and discharged on July 18, 2024. A treatment plan was completed on February 27, 2024 and an update was due by April 27, 2024 but not completed until May 7, 2024.
Client #2 was admitted on January 23, 2024 and discharged on July 17, 2024. A treatment plan was completed on March 4, 2024 and an update was due by May 4, 2024 but not completed until May 30, 2024.
Client #3 was admitted on January 2, 2024 and discharged on August 1, 2024. A treatment plan was completed on January 18, 2024 and an update was due by March 18, 2024 but not completed until March 27, 2024. Another treatment plan was completed on April 24, 2024 and an update was due by June 24, 2024 but not completed until July 15, 2024.
Client #5 was admitted on January 17, 2024 and still a current client at the time of inspection. A treatment plan was completed on March 20, 2024 and an update was due by May 20, 2024 but not completed until June 3, 2024. Another treatment plan was due by August 2, 2024 but no further treatment plans were completed at the time of the inspection.
Client #7 was admitted on March 7, 2024 and still a client at the time of inspection. A treatment plan was completed on May 13, 2024 and an update was due by July 12, 2024 but no further updates were completed at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the September 12, 2022 and September 13, 2023 licensure renewal inspections.
|
Plan of Correction
Clinical Director will review documentation standards and workflow as it relates to treatment plan updates with all staff by 10/1/2024. Clinical Director will review treatment plan analysis report with Counselors weekly to identify upcoming plans that are due. Clinical Director (weekly), Division Director (quarterly), and CQI Department (biannually) will conduct audits of charts to ensure compliance. Any issues noted will be addressed by the Clinical Supervisor with the clinician in a documented Clinical Supervision Session, and corrected within 48 hours. |
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 a review of client records, the facility failed to complete case consultations in three of seven applicable records reviewed. Per agency policy and procedures, case consults are to be completed within 90 days of admission.
Client #1 was admitted on January 31, 2024 and discharged on July 18, 2024. There was no documentation of a case consultation being completed for this client.
Client #2 was admitted on January 23, 2024 and discharged on July 17, 2024. There was no documentation of a case consult being completed for this client.
Client #7 was admitted on March 7, 2024 and still a client at the time of inspection. There was no documentation of a case consult being completed for this client.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the September 12, 2022 and September 13, 2023 licensure renewal inspections.
|
Plan of Correction
Clinical Director will review documentations standards as it relates to Case Consultations by 10/1/2024. Administrative staff will run a weekly census to determine which client are due for case consults and distribute weekly. Clinicians will complete identified case consults. Clinical Director (monthly), Division Director(quarterly) and CQI department (biannually) will complete chart audits to ensure compliance. Any issues noted will be addressed by the Clinical Supervisor with the clinician in a documented Clinical Supervision Session, and corrected within 48 hours. |
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.
|
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 treatment plan updates were submitted and approved by the Department for the September 12, 2022 and September 13, 2023 annual licensing inspections. Treatment plan updates were again found to be a deficiency in the August 13, 2024 licensing inspection.
A plan of correction for case consultations were submitted and approved by the Department for the September 12, 2022 and September 13, 2023 annual licensing inspections. Case consultations were again found to be a deficiency in the August 13, 2024 licensing inspection.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
Division Director will review current and past POC to with Clinical Director by 10/1/2024 and at least monthly in supervision. Chart Audits will be conducted Monthly by Clinical Director, Quarterly by Division Director and Biannually by CQI Department. Division Director and Clinical Director will review findings monthly. CQI and Outpatient Department will review findings during biannual audit meetings to ensure compliance with POC. Deficiencies will be addressed with Clinicians through documented performance improvement plans and progressive corrective action. |