INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 11, 2022 through May 12, 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 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 six personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that two employees received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #4 was hired as a counselor on February 5, 2020 and was due to have the communicable disease trainings no later than February 5, 2021. However, there was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection and the HIV/AIDS training was not completed until May 6, 2022.
Employee #5 was hired as a counselor on April 12, 2021 and was due to have the communicable disease trainings no later than April 12, 2022. However, there was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
This is a repeat citation from the May 29, 2020 and June 22, 2021 annual licensing inspections.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The two staff members have each completed the required TB/STD trainings on 6/6/22 and 6/7/22. Employee #4 completed the HIV/AIDS training on 5/6/22, and Employee #5 completed HIV/AIDS training on 7/20/21. These certificates were unavailable at the time of the review but have since been located.
Going forward, the Clinical Supervisor will ensure that all trainings are completed within required timeframes and according to the annual training plan for each employee. A full review of all trainings will be completed at least monthly to ensure that all staff trainings are up to date, and to ensure that any staff who are nearing the deadline will be scheduled to complete the training prior to the due date.
Additionally, the Program Director will meet quarterly with the Clinical Supervisor to review training records to assure that this is attended to. This will be documented in a supervision note
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of one applicable record reviewed.
Employee # 4 was hired as a counselor on February 5, 2020 and has remained in that position since. The facility's training year that was reviewed was from January 2021 through December 2021. Employee #4's personnel record only documented 15 hours of training for the period reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This staff member has completed 57 hours of training for the year 2021-2022, more than meeting the 25-hour requirement.
Going forward, the Clinical Supervisor will ensure that all training hours are completed within required timeframes and according to the annual training plan for each employee. A full review of all trainings will be completed at least monthly to ensure that all staff trainings are up to date, and to ensure that any staff who are nearing the deadline will be scheduled to complete the training prior to the due date.
Additionally, the Program Director will meet quarterly with the Clinical Supervisor to review training records to assure that this is attended to. This will be documented in a supervision note
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705.7 (b) (3) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(3) Clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
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Observations
Based on a physical plant inspection on May 12, 2022, the facility failed to store the utensils in a clean enclosed area after each usage.
The utensils were in an unenclosed area in the dining room at 2:47 p.m., between the lunch and dinner meals.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
We normally use individually wrapped, single use plastic utensils. At the time of the review, there had been a delay in delivery of the individually wrapped utensils, and bulk utensils were being used. Individually wrapped utensils have since been delivered and continue to be utilized.
Food service staff will monitor all supplies and will ensure that supplies are ordered far enough in advance to account for delays in delivery.
In any case where individually wrapped utensils are not available, any bulk utensils will be stored in a covered dispensing container.
The Program Director reviewed these regulations with food service staff on 5/16/2022 along with the new Cook 3, start date May 23, 2022.
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705.10 (c) (2) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(2) Maintain at least one portable fire extinguisher with a minimum of an ABC rating in each kitchen.
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Observations
Based on a physical plant inspection on May 12, 2022, the facility failed to ensure that the kitchen contained an ABC rated fire extinguisher.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 5/18/22, an ABC class fire extinguisher has been installed in addition to the K class fire extinguisher in the kitchen area.
Fire Extinguishers are inspected at least monthly by facility staff which is documented on the fire Extinguisher tags and in the safety report. The Program Director will review the safety report each month to ensure compliance.
In addition, fire extinguishers are monitored by the CQI Department during quarterly CQI site inspections and any findings will be reported to the Program Director for immediate action.
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705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of six personnel records, the facility failed to ensure that each staff was instructed in the use of the fire extinguishers upon employment in one record reviewed.
Employee #6 was hired as a counselor on September 20, 2021 and was due to be trained in the use of fire extinguishers by September 27; however, fire safety training was not documented as complete until March 29, 2022.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will ensure that all new hires receive the adequate fire safety training within the first 7 days of employment. This will be done by reviewing all new hire requirements with each new employee at the end of their first 5 days of employment. Any staff who have not yet had the training at that point will receive it immediately.
This will be documented in the staff file for each employee.
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705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of fire drill logs from July 2021 through April 2022, the facility failed to ensure that fire drill logs included the exit route used for each fire drill conducted.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The program had been using an older version of the fire drill log which did not have a space to document the exit rout utilized for each drill.
On 6/3/22, the Deputy Regional Director forwarded to the Program Director the correct log form which includes documentation of the exit route utilized during the drill.
The Program Director will review the correct form with all staff responsible for documentation of fire drills no later than 6/17/22.
The Quality Assurance Department will conduct at least quarterly audits to include a review of fire drill logs using an auditing tool which includes this as a specific item. Any issues noted will be brought to the immediate attention of the Program Director and will be included on a performance improvement plan.
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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 three applicable records reviewed.
Client #11 was admitted to Residential Rehabilitation activity on January 9, 2022 and discharged Against Medical Advise (AMA) on January 28, 2022. The facility failed to follow their policy related to AMA 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
This will be completed for all ASA discharges. This is the responsibility of the primary Counselor for the respective client. If the primary Counselor is not present, then the Clinical Supervisor will notify the Emergency Contact.
The Clinical Supervisor and Program Director will review the policy again with all staff in an in-service training no later than 6/10/22.
The Clinical Supervisor and will review all client files at time of discharge to ensure that this has been completed. Any chart missing this notification will be brought to the attention of the clinician to make immediate notification to the documented emergency contact.
The Program Director will conduct at least monthly chart audits using our quantitative audit tool, which lists this as a specific item for review.
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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. |
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.
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Observations
Based on a review of personnel records, the facility failed to ensure that personnel records contained a reviewed and signed annual written staff performance evaluation in two of four applicable records.
Employee # 3 was hired as a Clinical Supervisor on December 23, 2019 and is current in that position. The annual written staff performance evaluation for the 2021 calendar year period was not signed or dated by the employee as of the date of the inspection.
Employee #4 was hired as a counselor on February 5, 2020 and is current in that position. The annual written staff performance evaluation for the 2021 calendar year period was not signed or dated by the employee 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
Both employees annual evaluation had been completed and reviewed with the employees; however, the employees' had not acknowledged their evaluation in our electronic tracking system. Employee # 3 acknowledged her evaluation on 5/16/2022 and employee #4 will acknowledge his evaluation by 6/22/2022.
In the future, ensuring acknowledgement will be a part of the process of review, and the supervisor will document in a supervision note that the evaluation was reviewed. The employees' will sign the supervision note as well as acknowledging the evaluation in the system. The supervisor will follow up with the employee in the next supervision session to ensure that this acknowledgement has occurred.
This will done by the Clinical Supervisor and Program Director with all evaluations (such as for the close of a new employee's orientation period) for their direct reports beginning immediately.
Annual Evaluations are completed in January of each year, and so for the Annual Evaluation process, specifically, this will be completed by 1/31/23.
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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 twenty-one records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in four records reviewed. Additionally, the facility failed to keep disclosures of client identifying information with the limits established by Pa Code 255.5 (b) in four records reviewed.
Client #3 was admitted to the Detox activity on October 18, 2021 and was discharged on October 23, 2021. The record contained documentation that personally identifying information was sent to an outside treatment provider on October 21, 2021, with no consent to release information form signed by the client.
Client #6 was admitted to the Detox activity on May 6, 2022 and was active at the time of the inspection. The consent to release information forms to the funding source and a county agency, both signed by the client on May 6, 2022, allowing for the release of UDS results, which exceeds the limits established in Pa Code 255.5(b).
Client #11 was admitted to the Residential Rehabilitation activity on January 9, 2022 and discharged on January 28, 2022. The consent to release information form to the funding source signed by the client on January 9, 2022, allowed for the release of assessments, mental health records, medication records, and lab results, which exceeds the limits established in Pa Code 255.5(b).
Client #12 was admitted to the Residential Rehabilitation activity on April 19, 2022 and was active at the time of the inspection. The consent to release information form to the funding source signed by the client on April 19, 2022, allowed for the release of assessments, physical/medical records, treatment plan(s), progress notes, discharge summary, case consultations, mental health records, medication records, lab results, and urinalysis results, which exceeds the limits established in Pa Code 255.5(b).
Client #15 was admitted to the Intake, Evaluation, and Referral activity on July 23, 2021. The record did not contain a client signed consent to release information form to the funding source and there was evidence of billing.
Client #17 was admitted to the Intake, Evaluation, and Referral activity on September 8, 2021. The record contained documentation that the client was referred to two outside treatment providers, to whom the record contained no client signed consent to release information forms.
Client #21 was admitted to the Intake, Evaluation, and Referral activity on March 19, 2021. The consent to release information form to the funding source signed by the client on March 19, 2022, allowed for the release of assessments, mental health records, medication records, and urinalysis results, which exceeds the limits established in Pa Code 255.5(b). Additionally, the record contained documentation that the client was referred to an outside treatment provider, to whom the record contained no client signed consent to release information form.
This is a repeat citation from the December 23, 2020 and June 22, 2021 annual licensing inspections.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All current staff members with responsibility for completion of releases will attend the DDAP web-based Drug and Alcohol Confidentiality Training delivered by DDAP. This will be completed by 6/30/22. Client #6 was corrected on 5/11/2022. Client #12 will be corrected by 6/13/2022. Client was notified of error and will return to correct his consent.
In ongoing monthly all-staff meetings this will be a standing agenda item with the Clinical Supervisor leading an interactive discussion using examples of information which can and cannot be disclosed. This will be documented with a sign-in sheet.
The Clinical Supervisor will complete at least bi-weekly audits of a sample of charts including a qualitative review of consent forms to ensure that all information to be released is within the established limits. Any issues noted will be brought to the immediate attention of the clinician and corrected within 48 hours.
The Program Director will conduct at least monthly audits of the charts will bring any issues noted to the attention of the Clinical Supervisor to be addressed with the clinician and corrected within 48 hours. The Division Director will complete at least quarterly audits.
The Quality Assurance department will conduct quarterly audits which will result in a Performance Improvement Plan developed in collaboration with program management to address any issues identified.
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709.30 (1) 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.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on a review of twenty-one records, the facility failed to include written acknowledgement by clients that they have been notified of their rights, in seven records reviewed.
Client #15 was admitted to the Intake, Evaluation, and Referral activity on July 23, 2021.
Client #16 was admitted to the Intake, Evaluation, and Referral activity on August 21, 2021.
Client #17 was admitted to the Intake, Evaluation, and Referral activity on September 8, 2021.
Client #18 was admitted to the Intake, Evaluation, and Referral activity on October 6, 2021.
Client #19 was admitted to the Intake, Evaluation, and Referral activity on November 17, 2021.
Client #20 was admitted to the Intake, Evaluation, and Referral activity on January 13, 2022.
Client #21 was admitted to the Intake, Evaluation, and Referral activity on March 19, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A miscommunication regarding the completion of documentation led to this acknowledgement not being completed for individuals who we only assessed, and not admitted to the program.
Effective immediately, all individuals who are assessed will complete acknowledgement of rights, regardless of whether or not they are admitted to the program.
The Clinical Supervisor will review our documentation workflow which does specify that this acknowledgement be completed for all individuals assessed and/or admitted. This will be documented with a sign in sheet. This will occur no later than 6/17/22.
The Clinical Supervisor will complete at least bi-weekly audits of a sample of charts including a using our quantitative audit tool to ensure that all individuals has a signed acknowledgment of their rights in the chart. Any issues noted will be brought to the immediate attention of the clinician and corrected within 48 hours.
The Program Director will conduct at least monthly audits of the charts will bring any issues noted to the attention of the Clinical Supervisor to be addressed with the clinician and corrected within 48 hours. The Division Director will complete at least quarterly audits.
The Quality Assurance department will conduct quarterly audits which will result in a Performance Improvement Plan developed in collaboration with program management to address any issues identified.
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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 a review of unusual incident reports provided by the facility, the facility failed to ensure that events at the facility requiring the presence of police, fire, or ambulance personnel were reported to the Department within three business days. EMS personnel were onsite on April 12, 2022 and April 11, 2022 and police were onsite on March 20, 2022, however, the incidents were not reported to the Department as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This unusual incident was since sent to DDAP on 5/12/22.
The DDAP Reviewer was able to show the Program Director how to ensure that a submitted incident report has been successfully uploaded to the DDAP ERS system.
As an additional aid, our internal incident reporting system has been updated to include an email prompt alerting the Program Director that an incident may need to be reported to DDAP with a link to the DDAP ERS portal.
The Program Director will also review all incident submissions and reference the DDAP regs regarding unusual incident reporting to ensure that any incident meeting the criteria is reported.
The Quality Assurance department also conducts at least quarterly programs reviews which include a review of incident logs. Any issues noted will result in a Performance Improvement Plan developed in collaboration with program management to address any issues identified.
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709.63(a)(2) LICENSURE D & A support plan
709.63. 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:
(2) Drug and alcohol support plan.
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Observations
Based on a review of seven 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 drug and alcohol support plan completed within 24 hours, which is the policy of the project, in three of seven records reviewed.
Client #3 was admitted on October 18, 2021 and discharged on October 23, 2022. The drug and alcohol support plan was due to be completed by October 19, 2021; however, it was not completed until October 21, 2021.
Client #4 was admitted on January 7, 2022 and discharged on January 28, 2022. The drug and alcohol support plan was due to be completed by January 8, 2022; however, it was not completed until January 10, 2022.
Client #6 was admitted on May 6, 2022 and was active at the time of the inspection. The drug and alcohol support plan was due to be completed by May 7, 2022; however, it was not completed until May 10, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will be re-trained in an in-service no later than 6/17/22 conducted by the Clinical Supervisor regarding Drug and Alcohol Support Plans, and how to properly document this in the record.
The Clinical Supervisor will send a daily reminder to clinicians at the beginning of each morning to discuss which clients are due for Drug and Alcohol Support Plans. Clinical staff will route all Drug and Alcohol Support Plans to the Clinical Supervisor for approval. Calendars are being utilized to keep close track of time-sensitive dates for each client. Upcoming updated Drug and Alcohol Support Plans will be reviewed in daily Clinical Staff meeting.
The Clinical Supervisor will conduct weekly audits of a sample of charts using our quantitative audit tool in order to ensure that timely Drug and Alcohol Support Plans are completed for all charts. Any missing documentation will be brought to the attention of the clinician and completed within 48 hours.
The Program Director will conduct monthly audits of a sample of charts in order to ensure that timely Drug and Alcohol Support Plans are completed for all charts. Any missing documentation will be brought to the attention of the Clinical Supervisor in order to follow up with the clinician in supervision and completed within 48 hours.
The Quality Assurance Department will conduct at least quarterly audits to include all Plans of Correction to ensure full implementation. |
709.63(a)(8) LICENSURE Follow-up Information
709.63. 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) 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 three of three applicable records reviewed.
Client #1 was admitted on March 30, 2022 and discharged on April 4, 2022. The client record did not contain documentation of follow-up information.
Client #2 was admitted on January 26, 2022 and discharged on January 30, 2022. The client record did not contain documentation of follow-up information.
Client #4 was admitted on January 7, 2022 and discharged on January 28, 2022. The client record did not contain documentation of follow-up information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clients will be contacted post-discharge and this contact (or attempt) will be documented in our electronic health record on the Follow Up Contact Note created for this purpose. This will occur within 7 days of the date of the referral appointment for completions, and within 30 days for all other discharges.
This will be the responsibility of the Care Coordinator at the program. This will be done by running a discharge report from our electronic health record each day, and noting which clients require a follow-up contact.
Staff will be re-trained in an in-service no later than 6/17/22 conducted by the Clinical Supervisor regarding this regulation, and how to properly document follow-up in the record using our Follow-Up Contact form.
An internal tracking tool for each chart has been developed to help remind staff of upcoming documentation requirements. This includes follow-up post-discharge. The Clinical Supervisor will send a reminder to clinicians at the beginning of each month noting which clients are due for follow-up. Clinical staff will send all treatment plans to Clinical Supervisor for approval. Calendars are being utilized to keep close track of time-sensitive dates for each client. Upcoming follow-ups will be reviewed in daily Clinical Staff meeting.
The Clinical Supervisor will conduct weekly audits of a sample of charts in order to ensure that follow-ups are completed for all discharged charts. Any missing documentation will be brought to the attention of the clinician and completed within 48 hours.
The Program Director will conduct monthly audits of a sample of discharged charts. Any missing documentation will be brought to the attention of the Clinical Supervisor in order to follow up with the clinician in supervision and completed within 48 hours.
The Quality Assurance Department will conduct at least quarterly audits to include all Plans of Correction to ensure full implementation
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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 three of four records reviewed.
Client #8 was admitted on October 23, 2021 and discharged on November 23, 2021. The client record did not contain documentation of follow-up information.
Client #9 was admitted on February 11, 2022 and discharged on February 25, 2022. The client record did not contain documentation of follow-up information.
Client #10 was admitted on January 28, 2022 and discharged on February 27, 2022. The client record did not contain documentation of follow-up information.
Client #11 was admitted on January 9, 2022 and discharged on January 28, 2022. The client record did not contain documentation of follow-up information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clients will be contacted post-discharge and this contact (or attempt) will be documented in our electronic health record on the Follow Up Contact Note created for this purpose. This will occur within 7 days of the date of the referral appointment for completions, and within 30 days for all other discharges.
This will be the responsibility of the Care Coordinator at the program. This will be done by running a discharge report from our electronic health record each day, and noting which clients require a follow-up contact.
Staff will be re-trained in an in-service no later than 6/17/22 conducted by the Clinical Supervisor regarding this regulation, and how to properly document follow-up in the record using our Follow-Up Contact form.
An internal tracking tool for each chart has been developed to help remind staff of upcoming documentation requirements. This includes follow-up post-discharge. The Clinical Supervisor will send a reminder to clinicians at the beginning of each month noting which clients are due for follow-up. Clinical staff will send all treatment plans to Clinical Supervisor for approval. Calendars are being utilized to keep close track of time-sensitive dates for each client. Upcoming follow-ups will be reviewed in daily Clinical Staff meeting.
The Clinical Supervisor will conduct weekly audits of a sample of charts in order to ensure that follow-ups are completed for all discharged charts. Any missing documentation will be brought to the attention of the clinician and completed within 48 hours.
The Program Director will conduct monthly audits of a sample of discharged charts. Any missing documentation will be brought to the attention of the Clinical Supervisor in order to follow up with the clinician in supervision and completed within 48 hours.
The Quality Assurance Department will conduct at least quarterly audits to include all Plans of Correction to ensure full implementation.
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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 records and client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for training staff in HIV/AIDS and TB/STD within the regulatory timeframe was submitted and approved by the Department for the June 22, 2021 and May 29, 2020 annual licensing inspections. Training staff in HIV/AIDS and TB/STD within the regulatory timeframe was again found to be a deficiency in the May 11, 2022 through May 12, 2022 licensing inspection.
A plan of correction for obtaining client signed consent to release information forms and keeping disclosures of information within the limits established by 4 Pa. Code 255.5 was submitted and approved by the Department for the June 22, 2021 and December 23, 2020 annual licensing inspections. Obtaining client signed consent to release information forms prior to disclosing information and keeping disclosures within the limits of 4 Pa. Code 255.5 was again found to be a deficiency in the May 11, 2022 through May 12, 2022 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
REGARDING TRAINING:
The two staff members have each completed the required TB/STD trainings on 6/6/22 and 6/7/22. Employee #4 completed the HIV/AIDS training on 5/6/22, and Employee #5 completed HIV/AIDS training on 7/20/21. These certificates were unavailable at the time of the review but have since been located.
Going forward, the Clinical Supervisor will ensure that all trainings are completed within required timeframes and according to the annual training plan for each employee. A full review of all trainings will be completed at least monthly to ensure that all staff trainings are up to date, and to ensure that any staff who are nearing the deadline will be scheduled to complete the training prior to the due date.
Additionally, the Program Director will meet quarterly with the Clinical Supervisor to review training records to assure that this is attended to. This will be documented in a supervision note
REGARDING CONSENTS:
All current staff members with responsibility for completion of releases will attend the DDAP web-based Drug and Alcohol Confidentiality Training delivered by DDAP. This will be completed by 6/30/22.
In ongoing monthly all-staff meetings this will be a standing agenda item with the Clinical Supervisor leading an interactive discussion using examples of information which can and cannot be disclosed. This will be documented with a sign-in sheet.
The Clinical Supervisor will complete at least bi-weekly audits of a sample of charts including a qualitative review of consent forms to ensure that all information to be released is within the established limits. Any issues noted will be brought to the immediate attention of the clinician and corrected within 48 hours.
The Program Directors will conduct at least monthly audits of the charts will bring any issues noted to the attention of the Clinical Supervisor to be addressed with the clinician and corrected within 48 hours. The Division Director will complete at least quarterly audits.
The Quality Assurance department will conduct quarterly audits which will result in a Performance Improvement Plan developed in collaboration with program management to address any issues identified.
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