INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 28, 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 DRC 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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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of three personnel records, the facility failed to provide documentation showing that clinical supervisors had monthly meetings with their supervisors for the first six months of employment in that position, in one record reviewed.
Employee #3 was hired as the clinical supervisor on November 7, 2022 and has remained in that position. There was no documentation of monthly supervision in the personnel record.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Corp. OP Director conducts weekly supervision sessions with the Clinical Supervisor, which will be documented.
The Corp. OP Director will conduct monthly meetings with Clinical Supervisor for the first six months of employment in that position and will conduct meetings on a regular basis thereafter according to the developmental needs of the Clinical supervisor. |
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 three personnel records, the facility failed to ensure that one employee received the minimum of 4 hours of TB/STD training within the regulatory timeframe.
Employee # 2 was hired as the Facility Director on November 1, 2021 and was due to have the communicable disease trainings no later than November 1, 2023. However, there was no documentation of the completion of the TB/STD training 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
Employee #2 is no longer employed at Gaudenzia, Inc.
The Clinical Supervisor will review employee training plans for adherence quarterly.
CQI Manager will monitor employee training records during quarterly reviews. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of three personnel records and Staffing Requirements Facility Summary Report (SRFSR), the facility failed to demonstrate that a sufficient number of staff persons had CPR certification as only one full-time staff member was certified in CPR since the previous inspection and November 2023. As of the date of the inspection, no full-time staff members were certified in CPR.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor became CPR certified on 12/1/23.
The Clinical Supervisor will ensure that the newly hired Counselor is CPR certified within 90 days of hire.
The Clinical Supervisor will ensure that a certified staff person is present on all shifts. |
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 one record reviewed.
Client # 6 was admitted on August 16, 2023 and was active at the time of the inspection. The consent to release information form to the funding source was not signed until October 3, 2023, and there was evidence of billing prior to the client signed consent to release information form.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will review the workflow with the newly hired Counselor.
The Clinical Supervisor will conduct monthly audits to include dates of entry for consents.
The Corp. OP Director will conduct quarterly chart audits to include a review of consents.
The CQI Manager conducts quarterly chart reviews to include consents. |
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 and the facility ' s policies and procedures, the facility failed to ensure that an individual treatment and rehabilitation plan was developed with the client within 30 days of admission, per the facility policy, in three of six applicable records reviewed.
Client # 3 was admitted on February 7, 2023 and was discharged on May 9, 2023. The individual treatment and rehabilitation plan was due to be completed by March 7, 2023; however, it was not completed prior to the client ' s discharge.
Client # 4 was admitted on May 22, 2023 and was discharged on August 8, 2023. The individual treatment and rehabilitation plan was due to be completed by June 22, 2023; however, it was not completed until August 8, 2023.
Client # 8 was admitted on July 17, 2023 and was active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by August 17, 2023; however, it was not completed until August 31, 2023.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will run the Treatment plan Analysis Report monthly.
The Counselor will use the Upcoming Treatment Plan Widget to ensure timely completion of treatment plan updates.
The CQI Manager will conduct quarterly chart audits.
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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 client records, the facility failed to ensure that treatment and rehabilitation plans were reviewed updated at least every 60 days in three of five applicable records reviewed.
Client # 5 was admitted on February 17, 2023 and was discharged on October 7, 2023. The individual treatment and rehabilitation plan was completed on March 17, 2023, and a treatment plan update was due to be completed by May 17, 2023; however, the treatment plan update was not completed until September 16, 2023.
Client # 7 was admitted on September 5, 2023 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on September 16, 2023, and a treatment plan update was due to be completed by November 16, 2023; however, the treatment plan was not updated prior to the date of the inspection.
Client # 8 was admitted on July 17, 2023 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on August 31, 2023, and a treatment plan update was due to be completed by October 31, 2023; however, the treatment plan update was not completed until November 21, 2023.
This is a repeat citation from the December 12, 2022 and December 15, 2021 annual licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will run the Treatment plan Analysis Report monthly to ensure that all Treatment Plans are completed in a timely manner, and remind clinicians of upcoming Tx plan updates..
The Counselor will use the Upcoming Treatment Plan 'widget' in the EHR to ensure timely completion of treatment plan updates.
The Corporate OP Director as well as the CQI Manager will conduct at least quarterly chart audits to ensure compliance. Any issues noted will be brought to the immediate attention of the Clinical Supervisor to be addressed directly with the clinicians in a documented supervision session and corrected within 48 hours. |
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 plan in four of four applicable records reviewed.
Client # 5 was admitted on February 17, 2023 and was discharged on October 7, 2023. The treatment plan completed on March 17, 2023, indicated that the client was to receive one individual session per week; however, the record only documented three individual sessions offered between May 11, 2023 and July 3, 2023.
Client # 6 was admitted on August 16, 2023 and was active at the time of the inspection. The treatment plan completed on September 12, 2023, indicated that the client was to receive one group session per week; however, the record contained no documentation of a group session the week of September 25, 2023.
Client # 7 was admitted on September 5, 2023 and was active at the time of the inspection. The treatment plan completed on September 16, 2023, indicated that the client was to receive one individual session per week and one group session per week; however, the record documented no individual sessions between September 30, 2023 and November 11, 2023 and no group session since October 7, 2023.
Client # 8 was admitted on July 17, 2023 and was active at the time of the inspection. The treatment plans completed on August 31, 2023 and November 21, 2023, indicated that the client was to receive one group session per week; however, the record contained no documentation of group sessions since November 1, 2023.
This is a repeat citation from the December 12, 2022 and December 15, 2021 annual licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Counselor and Clinical Supervisor will document No Show Notes to ensure the accuracy of the scheduling calendar daily.
The Clinical Supervisor will review the scheduling calendar weekly.
The CQI Manager will conduct quarterly reviews of service provision according to the treatment plan.
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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 client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include case consultation information quarterly, per facility policy, in three of five applicable records reviewed.
Client # 3 was admitted on February 7, 2023 and was discharged on May 9, 2023. There was no documentation that a case consultation occurred by the time of discharge.
Client # 5 was admitted on February 17, 2023 and was discharged on October 7, 2023. The first case consultation note was due to be completed by May 17, 2023; however, it was not documented until June 15, 2023. The next case consultation note was due to be completed by September 15, 2023; however, there were no additional case consultation notes documented prior to the client ' s discharge.
Client # 6 was admitted on August 16, 2023 and was active at the time of the inspection. A case consultation was due by November 16, 2023, however there was no documentation that one occurred by the time of the inspection.
This is a repeat citation from the December 12, 2022 and December 15, 2021 annual licensing inspections.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will run the Clinical Forms Audit Report monthly.
The Clinical Supervisor will conduct monthly clinical chart audits.
The Corporate OP Director as well as the CQI Manager will conduct at least quarterly chart audits to ensure compliance. Any issues noted will be brought to the immediate attention of the Clinical Supervisor to be addressed directly with the clinicians in a documented supervision session and corrected within 48 hours. |
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 upon discharge, in three of five applicable records reviewed.
Client # 1 was admitted on February 15, 2023 and was discharged on April 10, 2023. The record did not contain a discharge summary.
Client # 2 was admitted on May 24, 2023 and was discharged on June 9, 2023. The record did not contain a discharge summary.
Client # 4 was admitted on May 22, 2023 and was discharged on August 8, 2023. The record did not contain a discharge summary.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will review the workflow with the Counselor.
The Clinical Supervisor will conduct monthly clinical chart audits.
The Corporate OP Director as well as the CQI Manager will conduct at least quarterly chart audits to ensure compliance. Any issues noted will be brought to the immediate attention of the Clinical Supervisor to be addressed directly with the clinicians in a documented supervision session and corrected within 48 hours. |
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 four of four applicable records reviewed. The facility policy is to complete a follow up within thirty days of discharge if the client is not referred to an additional service and within seven days if they are referred to an additional service.
Client # 1 was admitted on February 15, 2023 and was discharged on April 10, 2023. The client record did not contain documentation of follow-up information.
Client # 2 was admitted on May 24, 2023 and was discharged on June 9, 2023. The client record did not contain documentation of follow-up information.
Client # 3 was admitted on February 7, 2023 and was discharged on May 9, 2023. The client record did not contain documentation of follow-up information.
Client # 5 was admitted on February 17, 2023 and was discharged on October 7, 2023. The client record did not contain documentation of follow-up information.
This is a repeat citation from the December 12, 2022 and December 15, 2021 annual licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will review the workflow with the Counselor.
The Clinical Supervisor will run Clinical Forms Audit monthly to track follow up call efforts.
Counselor will use Follow Up widget to track upcoming records requiring follow up.
The Clinical Supervisor will conduct monthly clinical chart audits.
The Corporate OP Director as well as the CQI Manager will conduct at least quarterly chart audits to ensure compliance. Any issues noted will be brought to the immediate attention of the Clinical Supervisor to be addressed directly with the clinicians in a documented supervision session and corrected within 48 hours. |
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 including follow-up information in the client record was submitted and approved by the Department for the December 15, 2021 and December 12, 2022 annual licensing inspections. Completing follow-up information was again found to be a deficiency in the November 28, 2023 licensing inspection.
A plan of correction for providing services according to the treatment plan was submitted and approved by the Department for the December 15, 2021 and December 12, 2022 annual licensing inspections. Providing services according to the treatment plan was again found to be a deficiency in the November 28, 2023 licensing inspection.
A plan of correction for completing case consultation notes according to facility policy was submitted and approved by the Department for December 15, 2021 and December 12, 2022 annual licensing inspections. Completing case consultation notes was again found to be a deficiency in the November 28, 2023 licensing inspection.
A plan of correction for updating treatment plans within the regulatory timeframe was submitted and approved by the Department for December 15, 2021 and December 12, 2022 annual licensing inspections. Updating treatment plans was again found to be a deficiency in the November 28, 2023 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will have ultimate responsibility for ensuring that this plan of correction is fully implemented and adhered to on an ongoing basis at the program.
Effective immediately, in addition to the on-site monitoring by the Clinical Supervisor described above, the Corporate Outpatient Director will provide ongoing oversight of each plan of correction item and will conduct documented reviews of the plan of correction on a quarterly basis and provide direct feedback to the Clinical Supervisor to be documented in supervision notes.
In addition to the local and regional monitoring described above, the Corporate Quality Assurance department will conduct at least quarterly reviews of the program to include a physical plant inspection, qualitative and quantitative chart audits, and a specific review of each plan of correction item. Any issues identified during these reviews will be immediately brought to the attention of the Clinical Supervisor to be corrected immediately, as well as being noted on the summary sheet which includes a Performance Improvement Plan to be developed in conjunction with program management. Any missing documentation or documentation requiring correction will be completed by the clinician within 48 hours. |