INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up inspection conducted on May 23, 2024, 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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705.22 (4) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential 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
During an on-site provisional license follow-up inspection on May 23, 2024, it was observed that the facility failed to ensure that garbage was stored in covered containers that prevent the penetration of insects and rodents as there was an uncovered dumpster at the end of the parking lot in the front of the building.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of June 21, 2024, the dumpster will be checked daily at the beginning of shift, middle of shift, and end of shift to ensure the lid is down by the Program Director. The Outpatient Director will conduct at least monthly inspections and report it to program management and document it in audit reports the results of the findings. |
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 nine client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in seven records reviewed.
Client # 2 was admitted on March 1, 2024 and was discharged on April 2, 2024. Per a discussion with the Facility Director, information such as client diagnosis was disclosed to the funding source, however, the consent to release information form to the funding source signed by the client on December 28, 2023, did not allow for the release of that information.
Client # 3 was admitted on February 22, 2024 and was active at the time of the inspection. Per a discussion with the Facility Director, information such as client diagnosis was disclosed to the funding source, however, the consent to release information form to the funding source signed by the client on December 27, 2023, did not allow for the release of that information.
Client # 4 was admitted on January 8, 2024 and was active at the time of the inspection. The record did not contain a client signed consent to release information form to the funding source; however, the record contained evidence that billing occurred.
Client # 5 was admitted on August 12, 2023 and was discharged on March 8, 2024. Per a discussion with the Facility Director, information such as client diagnosis was disclosed to the funding source, however, the consent to release information form to the funding source signed by the client on June 27, 2023, did not allow for the release of that information.
Client # 7 was admitted on December 18, 2023 and was active at the time of the inspection. The record did not contain a client signed consent to release information form to the funding source; however, the record contained evidence that billing occurred.
Client # 8 was admitted on January 22, 2024 and was active at the time of the inspection. Per a discussion with the Facility Director, information such as client diagnosis was disclosed to the funding source, however, the consent to release information form to the funding source signed by the client on January 22, 2024, did not allow for the release of that information.
Client # 9 was admitted on March 29, 2024 and was active at the time of the inspection. The record did not contain a client signed consent to release information form to the funding source; however, the record contained evidence that billing occurred. Additionally, the record contained documentation of a disclosure of information to a probation officer on May 16, 2024; however, the consent to release information form to the probation officer signed by the client on May 13, 2024, did not allow for the release of any information.
This is a repeat citation from the November 28, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On June 21, 2024, all DRC staff will be attending a training by the CQI Manager to review how to correctly fill out releases. Once the training is complete DRC staff will have 4 weeks to update releases of information and ensure they are completed correctly utilizing what they learned in the training. They will have until July 24, 2024 to complete updating all old consents. They will be expected to use their knowledge moving forward with all incoming clients beginning on June 24, 2024. |
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 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 the preliminary treatment plan, per the facility policy, in five of six applicable records reviewed.
Client # 3 was admitted on February 22, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by March 29, 2024; however, it was not completed until May 9, 2024.
Client # 4 was admitted on January 8, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by February 24, 2024; however, it was not completed until April 3, 2024.
Client # 6 was admitted on December 21, 2023 and was discharged on March 20, 2024. The individual treatment and rehabilitation plan was due to be completed by January 21, 2024; however, it was not completed prior to the client ' s discharge.
Client # 7 was admitted on December 18, 2023 and was active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by February 4, 2024; however, it was not completed prior to the inspection.
Client # 8 was admitted on January 22, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by February 22, 2024; however, it was not completed until April 5, 2024.
This is a repeat citation from the November 28, 2023 annual licensing renewal inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On June 21, 2024, all staff at DRC will be undergoing a treatment planning training, put on by the Corporate Outpatient Director. All staff are new staff and this training will show them the correct way to complete treatment plans. Additionally the workflow will be reviewed to discuss treatment plan frequency. The Corporate Outpatient will run the Treatment Plan Analysis on a monthly basis and send a list to all staff regarding outstanding treatment plans, as well as provide a list of treatment plans that are expiring and ensure they are completed prior to the expiration date. |
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 and updated at least every 60 days in one of one applicable record reviewed.
Client # 5 was admitted on August 12, 2023 and was discharged on March 8, 2024. The individual treatment and rehabilitation plan was completed on September 28, 2023, and a treatment plan update was due to be completed by November 28, 2023; however, no treatment plan updates were completed prior to the client ' s discharge.
This is a repeat citation from the November 28, 2023, 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
Starting June 24, 2024, Corporate Outpatient Director will run the Treatment Plan Analysis Report and send an email to all DRC staff of all outstanding Treatment Plans, as well as a list of clients who are coming do with Treatment Plans along with the date by which the treatment plan is to be completed before. This will be followed up on by the Corporate Outpatient Director at the end of each month to ensure all Treatment Plans are completed. Failure to do so will result in disciplinary action as per our disciplinary policy. |
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, in six of seven applicable records reviewed. Based on a discussion with the Facility Director, case consultation information is due to be completed quarterly.
Client # 1 was admitted on November 14, 2023 and was discharged on February 28, 2024. There was no documentation that a case consultation occurred by the time of discharge.
Client # 3 was admitted on February 22, 2024 and was active at the time of the inspection. There was no documentation that a case consultation occurred by the time of the inspection.
Client # 4 was admitted on January 8, 2024 and was active at the time of the inspection. The first case consultation note was due to be completed by April 8, 2024; however, it was not completed until May 9, 2024.
Client # 5 was admitted on August 12, 2023 and was discharged on March 8, 2024. There was no documentation that a case consultation occurred by the time of discharge.
Client # 7 was admitted on December 18, 2023 and was active at the time of the inspection. There was no documentation that a case consultation occurred by the time of discharge.
Client # 8 was admitted on January 22, 2024 and was active at the time of the inspection. The first case consultation note was due to be completed by April 22, 2024; however, it was not completed until May 20, 2024.
This is a repeat citation from the November 28, 2023, 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
Starting June 24, 2024, Corporate Outpatient Director will run the Clinical Forms Audit and send an email to all DRC staff of all outstanding Case Consultations, as well as a list of clients who are coming do with a Case Consult along with the date by which the case consult is to be completed before. This will be followed up on by the Corporate Outpatient Director at the end of each month to ensure all Case Consults are completed. Failure to do so will result in disciplinary action as per our disciplinary policy. |
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, in four of four applicable records reviewed. Based on a discussion with the Facility Director, the discharge summary is due to be completed within seven days of discharge.
Client # 1 was admitted on November 14, 2023 and was discharged on February 28, 2024. The record did not contain a discharge summary.
Client # 2 was admitted on March 1, 2024 and was discharged on April 2, 2024. The discharge summary was not completed until May 20, 2024.
Client # 5 was admitted on August 12, 2023 and was discharged on March 8, 2024. The record did not contain a discharge summary.
Client # 6 was admitted on December 21, 2023 and was discharged on March 20, 2024. The record did not contain a discharge summary.
This is a repeat citation from the November 28, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning on June 24, 2024, Outpatient Director will run the Details of Discharge Report on a biweekly basis and send a list of all discharges to staff that must be completed based on the client's discharge date. Staff will be given time weekly to complete discharge summaries. This will be followed up on at the end of the month to ensure all discharge summaries have been completed. Staff who fail to complete the discharge summaries as outlined at the end of the month will be subject to disciplinary action per our policy. |
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. Based on a discussion with the Facility Director, follow-up information is due to be documented within 7 days if the client was referred for aftercare or within 30 days if no referral was made.
Client # 1 was admitted on November 14, 2023 and was discharged on February 28, 2024. Follow-up information was not documented until May 21, 2024.
Client # 2 was admitted on March 1, 2024 and was discharged on April 2, 2024. Follow-up information was not documented until May 21, 2024.
Client # 5 was admitted on August 12, 2023 and was discharged on March 8, 2024. Follow-up information was not documented until May 23, 2024.
Client # 6 was admitted on December 21, 2023 and was discharged on March 20, 2024. The record did not contain documentation of follow-up information.
This is a repeat citation from the November 28, 2023, 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
Beginning on June 24, 2024, Outpatient Director will run the Details of Discharge Report on a biweekly basis and send a list of all follow ups to staff that must be completed based on the client's discharge date. This will be followed up on at the end of the month to ensure all follow ups have been completed. Staff who fail to complete the follow ups as outlined at the end of the month will be subject to disciplinary action per our policy |
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, December 12, 2022, and November 28, 2023 annual licensing inspections. Completing follow-up information was again found to be a deficiency in the May 23, 2024 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, December 12, 2022, and November 28, 2023 annual licensing inspections. Completing case consultation notes was again found to be a deficiency in the May 23, 2024 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, December 12, 2022, and November 28, 2023 annual licensing inspections. Updating treatment plans was again found to be a deficiency in the May 23, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning June 24, 2024, the Outpatient Director will be having weekly meetings with the Program Director to go over the Plan of Correction. The Outpatient Director will also be running reports and doing weekly chart audits of both new and old charts and providing them to the team for review and to make corrections as needed. These chart audits will focus on the areas related specifically to the Plan of Correction. Should issues continue as related to the POC, disciplinary action for staff will occur as pursuit to our disciplinary process. |