INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 12, 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 Outpatient 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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709.28 (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 client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in one of twelve client records reviewed.
Client #7 was admitted on February 13, 2023 and discharged on March 16, 2023. There was not a documented informed and voluntary consent from the client for their funder; however, the facility acknowledged billing had occurred.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Gaudenzia Harrisburg Outpatient is now utilizing an intake/admission Workflow Worksheet that is a checklist of all items to be completed at time of admission. The funder consent release is on this workflow and is to be done at time of assessment/evaluation on each client. This will be completed for every evaluation and reviewed by Clinical Supervisor and Program Director as part of monthly chart reviews to assure compliance. |
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 document treatment plan updates within the regulatory timeframe in three out of seven records reviewed.
Client #4 was admitted on June 16, 2022 and was discharged on May 8, 2023. A treatment plan was completed on July 18, 2022, and the next update was due no later than September 18, 2022; however, the next update was not completed until October 6, 2022.
Client #5 was admitted on December 27, 2022 and discharged on May 8, 2023. A treatment plan was completed on January 5, 2023 and the next update was due no later than March 5, 2022; however, there was no documentation that one was completed prior to discharge.
Client #11 was admitted on January 30, 2023 and was still active at the time of the inspection. A treatment plan was completed on March 10, 2023, and the next update was due no later than May 10, 2023; however, there was no documentation that one was completed prior to discharge.
This is a repeat citation from the March 28, 2022 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Gaudeniza Harrisburg Outpatient is now utilizing a chart audit review form that is completed as part of regular monthly chart audits by Clinical Supervisor and Program Director. Tx Plan and Tx Plan Updates and the required time frames are a part of this chart audit review form. Findings of these internal audits will be reviewed with clinicians during weekly Clinical Meetings and monthly Supervision Sessions by the Clinical Supervisor. This is on-going. |
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 the review of client records, the facility failed to document case consultations according to the facility ' s policy and procedures manual of every ninety days in two out of four applicable client records.
Client #8 was admitted on January 4, 2023 and still active at the time of the inspection. A case consultation was due no later than April 4, 2023. There was no documentation that a case consultation occurred.
Client #11 was admitted on admitted on January 30, 2023 and was still active at the time of the inspection. A case consultation was due on April 30, 2023; however, there was no documentation that a case consultation occurred.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Gaudeniza Harrisburg Outpatient is now utilizing a chart audit review form that is completed as part of regular monthly chart audits by Clinical Supervisor and Program Director. Case Consultations and the required time frames are a part of this chart audit review form. Findings of these internal audits will be reviewed with clinicians during weekly Clinical Meetings and monthly Supervision Sessions by the Clinical Supervisor. This is on-going. |
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 the review of client records, the facility failed to document a discharge summary in one out of three applicable client records.
Client #5 was admitted on December 27, 2022 and discharged on May 8, 2023. There was no documentation that a discharge summary was completed.
This is a repeat citation from the March 28, 2022 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Gaudeniza Harrisburg Outpatient is now utilizing a chart audit review form that is completed as part of regular monthly chart audits by Clinical Supervisor and Program Director. Discharge Summaries and the required time frames are a part of this chart audit review form for all closed charts. Findings of these internal audits will be reviewed with clinicians during weekly Clinical Meetings and monthly Supervision Sessions by the Clinical Supervisor. This is on-going. |
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 the review of client records, the facility failed to document follow up information according to the facility ' s policy and procedures manual within seven days of discharge if referred to another program or service and 30 days if the client declines a referral to another program or service in one out of three applicable client records.
Client #12 was admitted on June 29, 2022 and discharged on August 3, 2022. There was no documentation that any follow up was completed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Gaudenzia Harrisburg Outpatient is now utilizing a follow up "widget" in our EHR (Avatar) system that alerts the clinician as to when a follow up is due. The clinician will engage in the follow up as alerted. This will be reviewed by Clinical Supervisor and Outpatient Director on a weekly basis to assure compliance. This is effective immediately and is on-going. |