INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 5, 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., Vantage House 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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709.24 (a) 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:
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Observations
Based on a review of client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients in one of one applicable record reviewed.
Client #5 was admitted to residential rehabilitation level of care on October 11, 2022 and discharged against facility advice on February 9, 2023. The facility failed to follow their policy related to against facility advice discharges of calling the emergency contact within twelve hours.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As of 6/6/23, all staff have been re-trained regarding this requirement. The Clinician will be responsible for completing this within 12 hours, and the Program Director will review all discharges on a weekly basis to ensure that this has been completed. Any issues noted will be addressed by notifying the emergency contact immediately. This is also an item which is monitored during regular auditing. The Program Director will complete at least monthly audits of a sample of charts, and the QA Manager will conduct at least quarterly audits using a standardized tool developed for this purpose. Any issues noted will be addressed with the clinician in a documented supervision session and corrected immediately as noted above. |
709.51(b)(3)(i) LICENSURE Medical histories
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on the review of client records, the facility failed to follow their intake procedures to complete a medical history within 72 hours of admission in six out of seven records reviewed.
Client #1 was admitted on December 22, 2022 and was still active at the time of the inspection. A medical history was due no later than December 25, 2022; however, was completed on December 28, 2022.
Client # 2 was admitted on November 28, 2022 and was still active at the time of the inspection. A medical history was due no later than December 1, 2022: however, was completed on December 4, 2022.
Client # 3 was admitted on March 7, 2023 and was still active at the time of the inspection. A medical history was due no later than, March 10, 2023; however, it was completed on March 17, 2023.
Client # 4 was admitted on November 29, 2022 and was still active at the time of the inspection. A medical history was due no later than December 2, 2022; however, it was completed on December 8, 2022.
Client #5 was admitted on October 11, 2022 and discharged on February 9, 2023. A medical history was due no later than October 14, 2022: however, it was completed on October 19, 2022.
Client # 7 was admitted on July 11, 2022 and discharged on December 15, 2022. A medical history was due no later than July 14, 2022; however, it was completed on July 18, 2022.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
As of 6/6/2023, all staff have been re-trained regarding this requirement. The Clinician will complete all Biopsychosocials, including medical histories within 72 hours. This is also an item which is monitored during regular auditing. The Program Director will complete at least monthly audits of a sample of charts, and the QA Manager will conduct at least quarterly audits using a standardized tool developed for this purpose, including qualitative review of the completed Biopsychosocial form. Any issues noted will be addressed with the clinician in a documented supervision session, and corrected within 48 hours. |
709.51(b)(3)(ii) LICENSURE Drug & Alcohol History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on the review of client records, the facility failed to follow their intake procedures to complete a drug and alcohol history within 72 hours of admission in six out of seven records reviewed.
Client #1 was admitted on December 22, 2022 and was still active at the time of the inspection. A drug and alcohol history was due no later than December 25, 2022; however, was completed on December 28, 2022.
Client # 2 was admitted on November 28, 2022 and was still active at the time of the inspection. A drug and alcohol history was due no later than December 1, 2022: however, was completed on December 4, 2022.
Client # 3 was admitted on March 7, 2023 and was still active at the time of the inspection. A drug and alcohol history was due no later than, March 10, 2023; however, it was completed on March 17, 2023.
Client # 4 was admitted on November 29, 2022 and was still active at the time of the inspection. A drug and alcohol history was due no later than December 2, 2022; however, it was completed on December 8, 2022.
Client #5 was admitted on October 11, 2022 and discharged on February 9, 2023. A drug and alcohol history was due no later than October 14, 2022: however, it was completed on October 19, 2022.
Client # 7 was admitted on July 11, 2022 and discharged on December 15, 2022. A drug and alcohol history was due no later than July 14, 2022; however, it was completed on July 18, 2022.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
As of 6/6/2023, all staff have been re-trained regarding this requirement. The Clinician will complete all Biopsychosocials, including drug and/or alcohol histories within 72 hours. This is also an item which is monitored during regular auditing. The Program Director will complete at least monthly audits of a sample of charts, and the QA Manager will conduct at least quarterly audits using a standardized tool developed for this purpose, including qualitative review of the completed Biopsychosocial form. Any issues noted will be addressed with the clinician in a documented supervision session, and corrected within 48 hours. |
709.51(b)(3)(iii) LICENSURE Personal History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on the review of client records, the facility failed to follow their intake procedures to complete a personal history within 72 hours of admission in six out of seven records reviewed.
Client #1 was admitted on December 22, 2022 and was still active at the time of the inspection. A personal history was due no later than December 25, 2022; however, was completed on December 28, 2022.
Client # 2 was admitted on November 28, 2022 and was still active at the time of the inspection. A personal history was due no later than December 1, 2022: however, was completed on December 4, 2022.
Client # 3 was admitted on March 7, 2023 and was still active at the time of the inspection. A personal history was due no later than, March 10, 2023; however, it was completed on March 17, 2023.
Client # 4 was admitted on November 29, 2022 and was still active at the time of the inspection. A personal history was due no later than December 2, 2022; however, it was completed on December 8, 2022.
Client #5 was admitted on October 11, 2022 and discharged on February 9, 2023. A personal history was due no later than October 14, 2022: however, it was completed on October 19, 2022.
Client # 7 was admitted on July 11, 2022 and discharged on December 15, 2022. A personal history was due no later than July 14, 2022; however, it was completed on July 18, 2022.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
As of 6/6/2023, all staff have been re-trained regarding this requirement. The Clinician will complete all Biopsychosocials, including personal histories within 72 hours. This is also an item which is monitored during regular auditing. The Program Director will complete at least monthly audits of a sample of charts, and the QA Manager will conduct at least quarterly audits using a standardized tool developed for this purpose, including qualitative review of the completed Biopsychosocial form. Any issues noted will be addressed with the clinician in a documented supervision session and corrected within 48 hours. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to follow their intake procedures to complete a psychosocial evaluation within 72 hours of admission in six out of seven records reviewed.
Client #1 was admitted on December 22, 2022 and was still active at the time of the inspection. A psychosocial evaluation was due no later than December 25, 2022; however, was completed on January 7, 2023.
Client # 2 was admitted on November 28, 2022 and was still active at the time of the inspection. A psychosocial evaluation was due no later than December 1, 2022: however, was completed on December 10, 2022.
Client # 3 was admitted on March 7, 2023 and was still active at the time of the inspection. A psychosocial evaluation was due no later than March 10, 2023. There was no documentation that one was completed.
Client # 4 was admitted on November 29, 2022 and was still active at the time of the inspection. A psychosocial evaluation was due no later than December 2, 2022; however, it was completed on December 12, 2022.
Client #5 was admitted on October 11, 2022 and discharged on February 9, 2023. A psychosocial evaluation was due no later than October 14, 2022: however, it was completed on October 26, 2022.
Client #6 was admitted on August 4, 2022 and discharged on January 13, 2023. A psychosocial evaluation was due no later than August 7, 2022; however, it was completed on August 16, 2022.
Client # 7 was admitted on July 11, 2022 and discharged on December 15, 2022. A psychosocial evaluation was due no later than July 14, 2022; however, it was completed on August 5, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 6/6/2023, all staff have been re-trained regarding this requirement. The Clinician will complete all Biopsychosocials, including the psychosocial evaluation within 72 hours. This is also an item which is monitored during regular auditing. The Program Director will complete at least monthly audits of a sample of charts, and the QA Manager will conduct at least quarterly audits using a standardized tool developed for this purpose, including qualitative review of the completed Biopsychosocial form. Any issues noted will be addressed with the clinician in a documented supervision session, and corrected within 48 hours. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in five out of seven records reviewed.
Client #1 was admitted on December 22. 2022 and still active at the time of the inspection. A treatment plan update was completed on February 19, 2023. The next treatment plan update was due no later than March 19, 2023; however, it wasn ' t completed on March 31, 2023.
Client # 2 was admitted on November 28, 2022 and still active at the time of the inspection. A treatment plan was completed on February 4, 2023. The next treatment plan update was due no later than March 4, 2023; however, it wasn ' t completed on March 7, 2023.
Client #4 was admitted on November 29, 2022 and still active at the time of the inspection. A treatment plan was completed on April 3, 2023. The next treatment plan update was due no later than May 3, 2023, however, there was no documentation that one was completed.
Client #5 was admitted on October 11, 2022 and discharged on February 9, 2023. A treatment plan was completed on November 11, 2022. The next treatment plan update was due no later than December 11, 2022; however, it wasn ' t completed on December 13, 2023.
Client #6 was admitted on August 4, 2022 and discharged on January 13, 2023. A treatment plan was completed on November 1, 2022. The next treatment plan was due no later than, December 1, 2022; however, it wasn ' t completed on December 5, 2022.
This is a repeat citation from the May 17, 2022 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 6/6/2023, all staff have been re-trained regarding this requirement. The Clinician will complete all treatment plan updates every 30 days. This is also an item which is monitored during regular auditing. The Program Director will complete at least monthly audits of a sample of charts, and the QA Manager will conduct at least quarterly audits using a standardized tool developed for this purpose, including review of regular treatment plan updates. Any issues noted will be addressed with the clinician in a documented supervision session and corrected within 48 hours. |