INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 14, 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. People With Hope/Short-Term Program 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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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 16, 2022, 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 Program Director and/or Recovery Support Supervisor will ensure that the lids on the dumpsters located on the side of the building (sallyport/dumpster area) always remain closed when trash is not being placed in the receptacle.
To assist with this, effective 07/15/22 there has been signage placed in the sallyport/dumpster area that reiterates that information. Additionally, this area is now included in a daily rounds checklist to ensure the dumpster lids are closed. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection on June 16, 2022, the facility failed to maintain each bathroom in a functional and clean manner as the bathroom for rooms 204 and 202 were undergoing renovations, missing soap, paper towels, and the bathtub presented as unsanitary with what appeared to be vomit in the bottom.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
The bathtub noted was not in use by clients during the renovation process. While we did not note any "vomit-like" substance, we did note debris of some sort that may have been the result of client's gaining access to the bathroom at some point during or prior to the renovation's start.
The Program Director and/or Recovery Support Professional Supervisor (RSPS) will update the hourly rounds checklist sheet for the Recovery Support staff to include checking for soap, paper towels and the condition of the bathtub, toilet, etc. to ensure that the bathroom is maintained in a functional and clean manner. This will include those bathrooms that are undergoing renovations and/or repairs and are not in use by clients. This new process will begin 07/18/22.
If deficiencies are noted in this area, during the rounds, it will be noted on the checklist sheet and corrected immediately. The checklist will be reviewed weekly by the RSPS and analyzed for trends and to ensure compliance. Any such trends will be addressed in supervsion with staff as it occurs.
The Program Director will continue to collaborate with the Maintenance department to ensure that renovations are completed by 9/30/22.
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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 two of five applicable records reviewed.
Client #4 was admitted on March 15, 2022 and discharged Against Medical Advise (AMA) on March 19, 2022. The facility failed to follow their policy related to AMA discharges of calling the Emergency Contact within twelve hours.
Client #7 was admitted on May 17, 2022 and discharged Against Medical Advise (AMA) on May 20, 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
Plan of Correction:
The Program Director and/or Clinical Supervisor will continue to monitor confidential releases of information during monthly file audits to monitor client charts through monthly audits to ensure that all Emergency Contacts are called for clients who leave treatment AMA, in accord with Gaudenzia's policy,
and that there is a written record of such calls. Any discrepancies will be addressed during staff supervision.
The Program Director and/or Clinical Supervisor will facilitate a Clinical Documentation in-service training in which Emergency Contact protocols are reviewed, specifically regarding clients who discharge AMA. This training will be facilitated by 08/05/22.
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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.
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.
Gaudenzia will obtain a completed financial audit from the independent certified public accounting firm on or before September 30th of 2022.
The Chief Financial Officer will oversee this process. |
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 seven client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in one record reviewed.
Client #6 was admitted on January 18, 2022 and was January 19, 2022 The record contained documentation of identifying information and lab work released to a diagnostic laboratory on January 18, 2022, to whom there was no client signed consent to release information form.
This is a repeat citation from the June 23, 2021 and October 7, 2020 annual licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
The Program Director and/or Clinical Supervisor will review all other active charts and ensure that there is an informed and voluntary consent form for them as needed, to include releases for diagnostic laboratories.
The program Director and/or Clinical Supervisor will continue to monitor confidential releases of information during monthly file audits and address any discrepancies during staff supervision. The CQI department will also monitor confidentiality and releases of information during quarterly CQI file audits and will report findings to the Program Director.
As most of the clinical staff are new to the program, the Program Director and/or Clinical Supervisor will facilitate a Voluntary Consent/Releases of Information in-service with all clinical staff by 08/05/22.
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709.63(a)(7) LICENSURE Discharge summary
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:
(7) Discharge summary.
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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 complete discharge summary in two of five applicable records reviewed.
Client #3 was admitted on August 26, 2021 and was discharged on August 31, 2021. The client record did not contain documentation of a completed discharge summary.
Client #6 was admitted on January 18, 2022 and was discharged on January 19, 2022. The client record did not contain documentation of a completed discharge summary.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director and/or Clinical Supervisor will review all discharges from 07/01/22 to present to ensure that there is a complete discharge summary in all client records.
The Program Director and/or Clinical Supervisor will continue to monitor discharge summaries during monthly file audits and address any discrepancies during staff supervision. The CQI department will also monitor discharge summaries during quarterly CQI file audits and will report findings to the Program Director.
As most of the clinical staff are new to the program, the Program Director and/or Clinical Supervisor will facilitate a Discharge Summary training in-service with all clinical staff by 08/05/22.
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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 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 follow-up information in two of five applicable records reviewed.
Client #4 was admitted on March 15, 2022 and was discharged on March 19, 20212 The client record did not contain documentation of follow-up information.
Client #6 was admitted on January 18, 2022 and was discharged on January 19, 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
The Program Director and/or Clinical Supervisor will review all discharges from 07/01/22 and ensure that there is a written record documenting follow-up with clients in accord with Gaudenzia's policy.
The Program Director and/or Clinical Supervisor will continue to monitor follow-up with clients during monthly file audits and address any discrepancies during staff supervision. The CQI department will also monitor client follow-up during quarterly CQI file audits and will report findings to the Program Director.
The Program Director and/or Clinical Supervisor will facilitate a in-service training with the Intake/Aftercare Counselor and the Utilization Review Specialist by 08/05/22.
The Program Director will develop a tracking form to monitor and record all discharges and follow-up activity.
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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 client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for obtaining client signed consent to release information forms prior to disclosures of information was submitted and approved by the Department for the June 23, 2021 and October 7, 2020 annual licensing inspections. Obtaining client signed consent to release information forms prior to disclosing information was again found to be a deficiency in the June 14, 2022 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Deputy Regional Director and Program Director are responsible for ensuring that the plan of correction is implemented.
In addition to the monthly chart audits conducted by the Program Director, Clinical Supervisor and the quarterly chart audits conducted by the CQI department, the Deputy Regional Director will complete monthly Plan of Correction audits that specifically address the deficiencies in the plans of correction. The purpose of this audit is to ensure implementation of and compliance with the plan of correction.
These findings will be reviewed with the Program Director. Any discrepancies will be addressed with the appropriate clinical staff and appropriate action taken to ensure compliance.
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