INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on May 3, 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. 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
|
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
|
Observations
Based on a review of personnel records, the facility failed to provide a written individual training plan for each employee, appropriate to that employee's skill level that documented it was developed annually with input from both the employee and the supervisor in two out of three personnel records reviewed.
Employee #2 was hired on June 6, 1998 as a facility director and was still in that position as of the date of the inspection. The individual training plan did not have documentation that the plan was developed with input from both the employee and supervisor.
Employee #4 was hired on December 20, 2021 as a counselor and was still in that position as of the date of the inspection. The individual training plan did not have documentation that the plan was developed with input from both the employee and supervisor.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
Due to revisions made by the corporate training department as it relates to staff individualized training plans, supervisors neglected to obtain a separate staff signature verifying training goals were reviewed. Although new year training needs and goals are discussed in all performance reviews which receives staff signature a single training plan verification was not obtained. To correct this issue, all supervisors at Sunbury will review 2023 staff training needs and goals by June 15, 2023 and document this process in a supervisory session to be signed by the employee. Going forward this will be the same process in future years to ensure staff understand and participate in their own training goals. This will be part of the routine annual performance review requirement and will be reviewed for completion by facility Division Director. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
|
Observations
Based on the review of client records, the facility failed to document a complete medical history, per the facility ' s policy and procedures manual of completion at the time of the first appointment in five out of seven records.
Client # 2 was admitted on March 29, 2023 and still active at the time of the inspection. There was no documentation that a medical history was obtained.
Client # 3 was admitted on December 16, 2022 and was still active at the time of the inspection. A medical history was due no later than, December 16, 2022; however, it was completed on February 8, 2023.
Client # 4 was admitted on February 27, 2023 and still active at the time of the inspection. There was no documentation that a medical history was obtained.
Client # 6 was admitted on July 29, 2022 and discharged on January 27, 2023. There was no documentation that a medical history was obtained.
Client # 7 was admitted on February 1, 2023 and discharged on March 27, 2023. There was no documentation that a medical history was obtained.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
A clinical meeting will be held with staff by June 15, 2023 to address treatment management procedures specific to obtaining client medical history via completion on the biopsychosocial upon initial session. All clinical staff will be directed to complete the medical portion of the biopsychosocial at intake. In order to address all requirements during the initial session, all intake sessions will be extended in time to ensure priority is given to completing all applicable requirements of the client history. All clients (2, 3, 4, 6 & 7) as long as still active at the program, will have their medical history completed by June 22, 2023. The Division Director will review biopsychosocial documents for completion when submitted for approval as well as during the CQI process monthly. Clinical staff documentation will be monitored monthly in regular supervisory sessions. The QA Managers as well as the Corporate Outpatient Director will complete quarterly chart audits to ensure compliance. Any issues noted will be documented in a Performance Improvement Plan to be addressed with clinicians and corrected within 48 hours. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
|
Observations
Based on the review of client records, the facility failed to document a drug and alcohol history per the facility ' s policy and procedures manual of completion at the time of the first appointment in three out of seven applicable records.
Client # 2 was admitted on March 29, 2023 and still active at the time of the inspection. There was no documentation that a drug and alcohol history was obtained.
Client # 3 was admitted on December 16, 2022 and was still active at the time of the inspection. A drug and alcohol history was due no later than, December 16, 2022; however, it was completed on February 8, 2023.
Client # 7 was admitted on February 1, 2023 and discharged on March 27, 2023. There was no documentation that a drug and alcohol history was obtained.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
A clinical meeting will be held with staff by June 15, 2023 to address treatment management procedures specific to obtaining client drug & alcohol history via completion on the biopsychosocial upon initial session. All clinical staff will be directed to complete the drug & alcohol portion of the biopsychosocial at intake. In order to address all requirements during the initial session, all intake sessions will be extended in time to ensure priority is given to completing all applicable requirements of the client history. All clients (2,3 & 7)) as long as still active at the program, will have their drug & alcohol history completed by June 22, 2023. The Division Director will review biopsychosocial documents for completion when submitted for approval as well as during the CQI process monthly. Clinical staff documentation will be monitored monthly in regular supervisory sessions. The QA Managers as well as the Corporate Outpatient Director will complete quarterly chart audits to ensure compliance. Any issues noted will be documented in a Performance Improvement Plan to be addressed with clinicians and corrected within 48 hours. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
|
Observations
Based on the review of client records, the facility failed to document a personal history records per the facility ' s policy and procedures manual of completion at the time of the first appointment in five out of seven.
Client # 2 was admitted on March 29, 2023 and still active at the time of the inspection. There was no documentation that a personal history was obtained.
Client # 3 was admitted on December 16, 2022 and was still active at the time of the inspection. A personal history was due no later than, December 16, 2022; however, it was completed on February 8, 2023.
Client # 4 was admitted on February 27, 2023 and still active at the time of the inspection. There was no documentation that a personal history was obtained.
Client # 6 was admitted on July 29, 2022 and discharged on January 27, 2023. There was no documentation that a personal history was obtained.
Client # 7 was admitted on February 1, 2023 and discharged on March 27, 2023. There was no documentation that a personal history was obtained.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
A clinical meeting will be held with staff by June 15, 2023 to address treatment management procedures specific to obtaining client personal history via completion of the biopsychosocial upon initial session. All clinical staff will be directed to complete the personal history portion of the biopsychosocial at intake. In order to address all requirements during the initial session, all intake sessions will be extended in time to ensure priority is given to completing all applicable requirements of the client history. All clients (2, 3, 4, 6 & 7)) as long as still active at the program, will have their personal history completed by June 22, 2023. The Division Director will review biopsychosocial documents for completion when submitted for approval as well as during the CQI process monthly. Clinical staff documentation will be monitored monthly in regular supervisory sessions. The QA Managers as well as the Corporate Outpatient Director will complete quarterly chart audits to ensure compliance. Any issues noted will be documented in a Performance Improvement Plan to be addressed with clinicians and corrected within 48 hours. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on the review of client records, the facility failed to document a psychosocial evaluation in seven out of seven records.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
A clinical meeting will be held with staff by June 15, 2023 to address treatment management procedures specific to completion of the biopsychosocial upon initial session. All clinical staff will be directed to complete the biopsychosocial at intake. In order to address all requirements during the initial session, all intake sessions will be extended in time to ensure priority is given to completing all applicable requirements of the client history. All clients reviewed during this cite visit, as long as still active at the program, will have their biopsychosocial completed by June 22, 2023. The Division Director/supervisor will complete monthly audit reviews to ensure biopsychosocial histories are completed for each client. The CQI team as well as the Corporate Outpatient Director will in turn, complete their quarterly audits to address compliancy. The QA Managers as well as the Corporate Outpatient Director will complete quarterly chart audits to ensure compliance. Any issues noted will be documented in a Performance Improvement Plan to be addressed with clinicians and corrected within 48 hours. |
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:
|
Observations
Based on a review of client records, the facility failed to document a comprehensive treatment plan within 30 days of admission as indicated in the facility's policy and procedure manual in four out of six applicable records reviewed.
Client #2 was admitted on March 29, 2023 and still active at the time of the inspection. A comprehensive treatment plan was due no later than April 29, 2023; however, there was no documentation of it being completed at the time of the inspection.
Client #4 was admitted on February 27, 2023 and still active at the time of the inspection. A comprehensive treatment plan was due no later than March 27, 2023; however, there was no documentation of it being completed at the time of the inspection.
Client #6 was admitted on July 29, 2022 and discharged on January 27, 2023. A comprehensive treatment plan was due no later than August 29, 2022; however, there was no documentation of it being completed at the time of the inspection.
Client #7 was admitted on February 1, 2023 and discharged on March 27, 2023. A comprehensive treatment plan was due no later than March 1, 2023; however, it was completed on March 7, 2023.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
A clinical meeting will be held with staff by June 15, 2023 to address treatment management procedures specific to completion of the client comprehensive treatment plan to be done with the client within 30 days of admission into treatment. All clinical staff will be directed to complete the comprehensive treatment plan with the client prior to the 30th day. Staff will be reminded that comprehensive treatment plans can always be done early when the client is present. Comprehensive treatment plans will be completed no later than June 22, 2023 for those clients identified who are still active in treatment. The Division Director/Supervisor will conduct monthly chart audits to ensure comprehensive treatment plans are being completed within the 30 day time frame. Clinical staff documentation will be monitored monthly in regular supervisory sessions. The QA Managers as well as the Corporate Outpatient Director will complete quarterly chart audits to ensure compliance. Any issues noted will be documented in a Performance Improvement Plan to be addressed with clinicians and corrected within 48 hours. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
|
Observations
Based on a review of client records, the facility failed to provide a complete client record that included an aftercare plan information in two out of five applicable records reviewed. Per the facility ' s policy and procedure manual, the aftercare plan is to be started within 30 days of admission.
Client #4 was admitted on February 27, 2023 and still active at the time of the inspection. The client record did not have documentation of the aftercare plan being started.
Client #6 was admitted on July 29, 2022 and discharged on January 27, 2023. The client record did not have any documentation of an aftercare plan.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
A clinical meeting will be held with staff by June 15, 2023 to address treatment management procedures specific to continuing care/transition/discharge plan. Clinical staff will be reminded that the aftercare plan must be started within 30 days of admission into treatment and completed in it's entirety upon discharge. The Division Director will review for compliance during the monthly internal CQI audit process. Additionally, quarterly audits will be completed quarterly by the QA Manager as well the Corporate Outpatient Director. All audit results are documented monthly via SharePoint and results are reviewed with staff during monthly supervisory sessions.
|
709.93(a)(10) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(10) Discharge summary.
|
Observations
Based on a review of client records, the facility failed to provide a complete client record that included a discharge summary in one out of three applicable records reviewed.
Client #6 was admitted on July 29, 2022 and discharged on January 27, 2023.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
A clinical meeting will be held with staff by June 15, 2023 to address treatment management procedures specific to continuing care/transition/discharge plan. Clinical staff will be reminded that the discharge plan must be completed within 72 hours of a client's discharge from treatment. The Division Director/supervisor will review for compliance during the monthly internal CQI audit process. Additionally, quarterly audits will be completed by the Regional QA Manager as well the Corporate Outpatient Director. All audit results are documented monthly via SharePoint and results are reviewed with staff during monthly supervisory sessions. |
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.
|
Observations
Based on a review of client records, the facility failed to provide a complete follow-up information in one out of two applicable records reviewed.
Client #7 was admitted on February 1, 2023 and discharged on March 27, 2023. There was not documentation of follow up information in the record.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
A clinical meeting will be held with staff by June 15, 2023 to address treatment management procedures specific to client follow up after discharge. Staff will be reminded that for those clients referred to another program or service, upon receiving written client consent, a follow up phone call will occur within 7 days of discharge/referral. For all other types of discharges (ASA, completion, non ? compliance) a follow up phone call will be done within 30 days of client discharge. All follow up will be completed by the onsite Certified Recovery Specialist or other assigned staff. The Division Director/supervisor will review for compliance during the monthly internal CQI audit process using a standard tool which lists follow up as an item. Additionally, quarterly audits will be completed by the Regional QA Manager as well the Corporate Outpatient Director. All audit results are documented monthly via SharePoint and results are reviewed with staff during monthly supervisory sessions. Follow up reminders have been added in the electronic health record "My To Do List" for staff assigned. |