INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 23, 2023, 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., Outreach 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to ensure that one of five employees received a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum within the regulatory timeframe.
Employee # 5 was hired as a counselor on April 11, 2022 and was due to have the communicable disease trainings no later than April 11, 2023. However, the personnel record contained no documentation of the completion of the HIV/AIDS or TB/STD trainings as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will ensure that Employee 5 enrolls in the DDAP HIV/AIDS/STD training module. Due 8/31/23
The Counselor will attend the training and provide documentation of completion to the Program Director to be uploaded to our Relias web-based training system.
Due 12/31/23
The Program Director or Clinical Supervisor will conduct at least quarterly review of Individual Training plans to ensure that all employees are on track to complete trainings prior to required deadlines.
The Quality Assurance department will conduct at least quarterly reviews of the program, to include review of training records to ensure compliance. Any issues noted will be documented in a report and a performance improvement plan developed.
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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 23, 2023, the facility failed to ensure that garbage was stored in covered containers that prevent the penetration of insects and rodents as a trash receptacle in the sallyport of the building was uncovered.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Maintenance Department will affix a sign to the dumpster indicating, "DUMPSTER MUST BE CLOSED AFTER EVERY USE!".
8/11/23
The Program Director will collaborate with the Division Director for Residential Services to determine the best solution for ongoing monitoring for the open dumpster for the building, which houses several programs.
The Program Director will send an email to all building programs to remind staff to ensure that the dumpster remains closed after use.
8/11/23
The Quality Assurance Manager will monitor the dumpster during quarterly physical site inspections. Any issues noted will be noted in a report and brought to the immediate attention of the Program Director to be addressed immediately.
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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 eight client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in two records reviewed.
Client # 6 was admitted on April 11, 2023 and was active at the time of the inspection. Per a discussion with the Facility Director, information such as client progress and prognosis were disclosed to the funding source, however, the consent to release information form to the funding source signed by the client on April 11, 2023, did not allow for the release of that information.
Client # 8 was admitted on February 2, 2023 and was active at the time of the inspection. The consent to release information form to the funding source was not signed until March 1, 2023, and there was evidence of billing prior to the client signed consent to release information form.
This is a repeat citation from the June 15, 2022 and June 22, 2021 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will conduct an in-service training for staff to review the appropriate information to be released to various entities, and where to documents these using the consent forms in our electronic health record. 8/11/23
All staff will be registered to complete the updated DDAP Confidentiality training no later than 8/31/23.
The Clinical Supervisor and/or Program Director will complete at least monthly chart audits on a sample of open and closed charts, to include qualitative audit of the elements required on consent forms. Any issues noted will be addressed directly with the clinician responsible, documented in a clinical supervision note, and corrected within 48 hours.
The Quality Assurance department will conduct at least quarterly audits. Any issues noted will be noted in a report and brought to the immediate attention of the Program Director to be addressed as noted above.
On 8/7/23, the Program Director notified Client's 6 (discharged from program) and 8 (currently active in NX) via telephone regarding the disclosure of information prior to obtaining the signed release forms and documented the engagement in each client's EHR.
An independent note was entered into each of their charts to document the notification.
Counselor will obtain updated signed release forms from each client #8 during the next scheduled session.
If client #6 returns to treatment, his release will be completed correctly.
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709.92(a) 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:
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Observations
Based on a review of eight client records, the facility failed to ensure that an individual treatment and rehabilitation plan was developed with the client within 30 days of the preliminary treatment plan, per the facility policy, in two of six applicable records reviewed.
Client # 3 was admitted on August 31, 2022 and was discharged on April 28, 2023. The preliminary treatment plan was completed on August 31, 2022 and the individual treatment and rehabilitation plan was due to be completed by September 30, 2022; however, it was not completed until October 14, 2022.
Client # 7 was admitted on February 13, 2023 and was active at the time of the inspection. The preliminary treatment plan was completed on February 13, 2023 and the individual treatment and rehabilitation plan was due to be completed by March 15, 2023; however, it was not completed until June 12, 2023.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counselors will use the Treatment Plan widget
Counselors will use the updated workflows to monitor completion of treatment plans
The Clinical Supervisor and/or Program Director will complete at least monthly chart audits on a sample of open and closed charts. Any issues noted will be addressed directly with the clinician responsible, documented in a clinical supervision note, and corrected within 48 hours.
The Quality Assurance department will conduct at least quarterly audits. Any issues noted will be noted in a report and brought to the immediate attention of the Program Director to be addressed as noted
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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 eight client records, the facility failed to document treatment plan updates within the regulatory timeframe in one of three applicable records reviewed.
Client # 2 was admitted on August 5, 2022 and was discharged on November 14, 2022. The individual treatment and rehabilitation plan was completed on September 5, 2022, and the treatment plan update was due no later than November 5, 2022; however, no treatment plan update was completed prior to the client ' s discharge.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Counselors will use the Treatment Plan widget
Counselors will use the updated workflows to monitor completion of treatment plans
The Program Director will show Counselors how to run the Clinical Forms Audit Report in NX to assist with monitoring treatment plan completion.
The Clinical Supervisor and/or Program Director will complete at least monthly chart audits on a sample of open and closed charts. Any issues noted will be addressed directly with the clinician responsible, documented in a clinical supervision note, and corrected within 48 hours.
The Quality Assurance department will conduct at least quarterly audits. Any issues noted will be noted in a report and brought to the immediate attention of the Program Director to be addressed as noted
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709.92(c) LICENSURE Treatment and rehabilitation services
709.92. 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 six applicable records reviewed.
Client # 1 was admitted on July 18, 2022 and was discharged on August 31, 2022. The treatment plan completed on July 18, 2022, indicated that the client was to receive one individual session per week and three group sessions per week; however, the record contained no documentation of an individual session between July 18, 2022 and August 3, 2022. Additionally, the record only contained documentation of one group session during the entire treatment episode.
Client # 2 was admitted on August 5, 2022 and was discharged on November 14, 2022. The treatment plans completed on August 5, 2022 and September 5, 2022, indicated that the client was to receive one individual session per week; however, there was no documentation of an individual session the weeks of August 8, 2022, August 15, 2022, August 29, 2022, September 5, 2022, September 12, 2022, and September 19, 2022.
Client # 7 was admitted on February 13, 2023 and was active at the time of the inspection. The treatment plan completed on February 13, 2023, indicated that the client was to receive one individual session per week; however, the record contained no documentation of individual sessions between March 15, 2023 and March 29, 2023, or between April 19, 2023 and May 16, 2023.
Client # 8 was admitted on February 2, 2023 and was active at the time of the inspection. The treatment plan completed on February 22, 2023, indicated that the client was to receive one individual session per week; however, the record contained no documentation of individual sessions between March 22, 2023 and April 5, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director provided training to Counselors on how to document frequency of services in the treatment plan form on our EHR on 6/28/23.
The Clinical Supervisor and/or Program Director will complete at least monthly chart audits on a sample of open and closed charts, to include qualitative audit of the treatment plan as compared to delivery of services noted. Any issues noted will be addressed directly with the clinician responsible, documented in a clinical supervision note, and corrected within 48 hours.
The Quality Assurance department will conduct at least quarterly audits. Any issues noted will be noted in a report and brought to the immediate attention of the Program Director to be addressed as noted above.
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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 a review of eight client records and the facility ' s policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include case consultation notes quarterly, per the facility ' s policy, in three of four applicable records reviewed.
Client # 3 was admitted on August 31, 2022 and was discharged on April 28, 2023. The client record did not contain documentation of case consultation notes.
Client # 5 was admitted on September 27, 2022 and was discharged on February 21, 2023. The client record did not contain documentation of case consultation notes.
Client # 7 was admitted on February 13, 2023 and was active at the time of the inspection. The case consultation notes were entered until June 2, 2023.
This is a repeat citation from the June 15, 2022, June 22, 2021, and October 1, 2020 annual licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, Counselors will run the Clinical Forms Audit from our EHR weekly to monitor completion of case consultations. 8/2/23
The Program Director will conduct monthly case consultation meetings with Counselors to review any cases due for a consultation. For case consultations that are due prior to the scheduled meeting, Counselors will meet individually with the Program Director. Once the electronic form is completed, the Case Consultation will be routed to all clinical team members for feedback and signature.
The Clinical Supervisor and/or Program Director will complete at least monthly chart audits on a sample of open and closed charts. Any issues noted will be addressed directly with the clinician responsible, documented in a clinical supervision note, and corrected within 48 hours.
The Quality Assurance department will conduct at least quarterly audits. Any issues noted will be noted in a report and brought to the immediate attention of the Program Director to be addressed as noted above.
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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 ensure a complete client record included information relative to the client's involvement with the project to include a discharge summary, in two of five applicable records reviewed.
Client # 2 was admitted on August 5, 2022 and was discharged on November 14, 2022. The client record did not contain documentation of a discharge summary.
Client # 4 was admitted on December 27, 2022 and was discharged on February 24, 2023. The client record did not contain documentation of a discharge summary.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will ensure that Counselors complete Discharge Summaries as needed.
The Administrative Coordinator will run the Details of Discharge Report from our EHR weekly in order to monitor compliance. The Administrative Coordinator will review the report and inform the Program Director of deficiencies. 8/11/23
The Clinical Supervisor and/or Program Director will complete at least monthly chart audits on a sample of closed charts. Any issues noted will be addressed directly with the clinician responsible, documented in a clinical supervision note, and corrected within 48 hours.
The Quality Assurance department will conduct at least quarterly audits. Any issues noted will be noted in a report and brought to the immediate attention of the Program Director to be addressed as noted
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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 ensure a complete client record included information relative to the client's involvement with the project to include follow-up information, in two of three applicable records reviewed.
Client # 2 was admitted on August 5, 2022 and was discharged on November 14, 2022. The client record did not contain documentation of follow-up information.
Client # 4 was admitted on December 27, 2022 and was discharged on February 24, 2023. The client record did not contain documentation of follow-up information.
This is a repeat citation from the June 15, 2022 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Administrative Coordinator will place follow-up calls to discharged clients and enter the note into the chart.
The Administrative Coordinator will run the Details of Discharge Report from our EHR weekly in order to note which clients are due for a follow up contact. 8/11/23
The Clinical Supervisor and/or Program Director will complete at least monthly chart audits on a sample of closed charts. Any issues noted will be addressed directly with the clinician responsible, documented in a clinical supervision note, and corrected within 48 hours.
The Quality Assurance department will conduct at least quarterly audits. Any issues noted will be noted in a report and brought to the immediate attention of the Program Director to be addressed as noted above.
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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 personnel and client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction to ensure a complete client record included information relative to the client's involvement with the project to include case consultation notes was submitted and approved by the Department for the June 15, 2022, June 22, 2021, and October 1, 2020 annual licensing inspections. Including case consultations in the client record was again found to be a deficiency in the June 23, 2023 licensing inspection.
A plan of correction to ensure a complete client record included information relative to the client's involvement with the project to include follow-up information was submitted and approved by the Department for the June 15, 2022 annual licensing inspection. Including follow-up information in the client record was again found to be a deficiency in the June 23, 2023 licensing inspection.
A plan of correction for obtaining client consent to release information prior to disclosure was submitted and approved by the Department for the June 15, 2022 and June 22, 2021 annual licensing inspections. Obtaining client consent prior to disclosing information was again found to be a deficiency in the June 23, 2023 licensing inspection.
A plan of correction for ensuring staff complete the communicable disease trainings within the regulatory timeframe was submitted and approved by the Department for the June 15, 2022 annual licensing inspection. Completing the HIV/AIDS and TB/STD trainings was again found to be a deficiency in the June 23, 2023 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director is ultimately responsible for ensuring program compliance with Plans of Correction. The Program Director will complete monthly reviews of all POC items to ensure that they have been, and continue to be implemented. Any issues noted will be addressed with the appropriate party in a documented supervision session and corrected within 48 hours. In addition, the Quality Assurance department will conduct quarterly audits of the program, which include reviews of any open POCs. Any issues noted will be brought to the immediate attention of the Program Director to be addressed as noted above. |