INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 15, 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:
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Plan of Correction
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705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records and a discussion with facility staff, the facility failed to ensure that one staff was trained to perform assigned tasks during emergencies prior to being on shift.
Employee #4 was hired as a counselor on January 3, 2023 and is current in that position. Employee #4 began working shifts on January 3, 2023 but was not trained to perform assigned tasks during emergencies until February 13, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All new hires will receive fire safety training on their first date of hire. The Program Director will review training documentation for new hires within the first two weeks of hire. The CQI Manager will review employee training records as part of the quarterly physical site inspection. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the fire drill logs from July 2022 through May 2023, the facility failed to set off a fire alarm or smoke detector at any of the fire drills conducted during the period reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The program was under active renovation over the past year and was transferring between alarm companies. Verbal announcement of an active drill was provided by staff during that time. The Clinical Supervisor will receive training from the new alarm company on procedures to put the alarm system in test mode for subsequent fire drills. The Program Director will ensure that the fire alarm or smoke detector is activated for all fire drills. The Program Director will ensure that monthly fire drill logs are maintained. The CQI Manager will review monthly fire drill logs during quarterly physical site inspections. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to document that the client was notified, in writing, of the facility's decision to involuntarily terminate the client's treatment at the project in one applicable record reviewed.
Client #3 was admitted on November 23, 2022 and was involuntarily discharged on March 29, 2023. There was no documentation that the client was notified, in writing, of the facility's decision to involuntarily terminate.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counselors will send the Treatment Termination Notice (available in EHR) to clients at discharge. The Clinical Supervisor will train clinicians in the use of this form. The Clinical Supervisor will audit client charts to ensure that the Treatment Termination Notice has been sent to applicable discharged clients. The Program Director will incorporate a review of closed client charts during monthly clinical chart audits. The CQI Manager will review closed charts as part of the quarterly chart audit process. |
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 including follow-up information, in three of three applicable records reviewed.
Client #2 was admitted on October 11, 2022 and discharged on January 4, 2023. The client record did not contain documentation of follow-up information.
Client #3 was admitted on November 23, 2022 and was discharged on March 29, 2023. The client record did not contain documentation of follow-up information.
Client #4 was admitted on July 8, 2022 and was discharged on April 10, 2023. The client record did not contain documentation of follow-up information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The previous Case Manager passed away, which resulted in a lapse in Follow Up Contact calls for approximately two months. Since then, a new Case Manager has been hired.
As of 5/22/23, the new Case Manager has completed Follow Up Contact calls for all clients who were discharged between 3/29/23-4/30/23 and will continue doing so for subsequent discharges.
In the future any vacancy for any reason will be addressed by the Program Director making a complete review of that employee's job duties, and assigning coverage of all critical tasks, to include follow-up contacts within required timeframes.
The CQI Manager will conduct quarterly reviews of client discharges, to include chart audits which cover documentation of follow-up. Any issues noted will be brought to the attention of the Program Director, who will ensure that any required follow-up calls are completed within 48 hours
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