INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 16, 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, Inc. Outreach 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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704.11(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 personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee's # 2 and 5 received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee # 2 was hired on April 26, 2021, and promoted to current position on October 30, 2023. Employee # 2 was due to have the communicable disease trainings no later than April 26, 2023. There was no documentation in the personnel file of the completion of the HIV/AIDS training as of the date of the inspection.
Employee # 5 was hired as a counselor on April 26, 2021, and was still in this position at the time of the inspection. Employee # 5 was due to have the communicable disease trainings no later than April 26, 2022. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the June 15, 2022, June 23, 2023 annual licensing inspections.
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Plan of Correction
The Division Director will monitor all staff trainings quarterly.
The Clinical Supervisor will ensure that Staff 2 & 5 will complete the HIV/AIDS training along with TB and STD training by 9/30/2024.
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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Cameras were located in group rooms allowing therapy sessions to be seen.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A request for exemption was submitted to DDAP and approved.
All supervisory staff will have access to the video footage will attend a training course and sign a confidentiality form to ensure the privacy of all clients.
Forms will be updated in EHR to reflect the confidentiality of the use of video recording in all group areas.
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709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on six of eight applicable client records reviewed, the facility failed to provide a psychosocial evaluation in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicated a psychosocial evaluation be completed within thirty days of admission and include a narrative psychosocial assessment based on the data collected from the client ' s history.
Client # 1 was admitted on February 28, 2024, and was still active at the time of the inspection. The biopsychosocial evaluation did not include the counselor narrative psychosocial assessment required by the facility policy and procedure manual.
Client # 3 was admitted on January 31, 2024, and was still active at the time of the inspection. The biopsychosocial evaluation did not include the counselor narrative psychosocial assessment required by the facility policy and procedure manual.
Client # 4 was admitted on September 12, 2023, and was still active at the time of the inspection. There was no biopsychosocial or evaluation documented in the client record.
Client # 5 was admitted on July 20, 2023, and was discharged on January 23, 2024. The biopsychosocial evaluation did not include the counselor narrative psychosocial assessment required by the facility policy and procedure manual.
Client # 6 was admitted on January 23, 2024, and was discharged on March 6, 2024. The biopsychosocial evaluation did not include the counselor narrative psychosocial assessment required by the facility policy and procedure manual.
Client # 8 was admitted on October 4, 2023, and was discharged on March 4, 2024. There was no biopsychosocial or evaluation documented in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor will audit charts after the counselor has completed intake to ensure that all documentation has been completed correctly.
The clinical supervisor will conduct weekly staff meetings to ensure that all staff understand what is required of them for documentation, as well as provide counselors with updated flow sheets to follow and ensure that no documentation is missing.
The clinical supervisor will Focus more on discharge audits to ensure that discharge documentation is completed correctly by auditing 3 charts per counselor per month starting in the month of July 2024.
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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 review and update the treatment and rehabilitation plan at least every sixty days in three out of eight records.
Client # 2 was admitted on December 7, 2023, and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on February 28, 2024 and was to be updated by April 28, 2028. The update was not documented until May 15, 2024.
Client # 7 was admitted on October 26, 2023, and was discharged on February 16, 2024. A treatment and rehabilitation plan was developed on November 28, 2023 and was to be updated by January 28, 2024. There was no documentation of a treatment plan update in the client record.
Client # 8 was admitted on October 4, 2023, and was discharged on March 4, 2024. A treatment and rehabilitation plan was developed on December 19, 2023 and was to be updated by February 19, 2024. There was no documentation of a treatment plan update in the client record.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the June 23, 2023 annual licensing inspection.
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Plan of Correction
The clinical supervisor will ensure that all staff attend Treatment plan training by 07/31/2024
The Clinical Supervisor will audit charts monthly basis and The division Director will audit charts on a quarterly basis to ensure treatment plans are completed according within program guidelines and they remain timely. The findings of these audits will be reviewed on an individual basis with clinicians and this review will be documented in a supervision note. Any areas identified as needing to be fixed will be corrected within 48 hours.
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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 assure that counseling services are provided according to the individual treatment and rehabilitation plan in six of eight client records.
Client # 1 was admitted on February 28, 2024, and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan developed on March 20, 2024, indicated an individual session weekly and a group weekly. The last individual session documented was on April 24, 2024, and there were no groups documented from March 3, 2024 to March 30, 2024.
Client # 2 was admitted on December 7, 2023, and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan developed on February 28, 2024, indicated an individual session occur one time weekly. February only documented an individual session on February 16 and 21, 2024.
Client # 4 was admitted on September 12, 2023, and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan developed on February 13, 2024, and updated on April 11, 2024. Each indicated an individual session to occur one time weekly and a group session occur two times weekly. Individual sessions were only documented for December 8, January 12, and April 11, 2024. Group sessions that occurred October 2, 20, November 1, 8, 22, 27, December 4, 22, January 5, 30, February 1, March 5, 12, 19, 26, April 9, 2024, did not have documentation of a second session during those weeks.
Client # 5 was admitted on July 20, 2023, and was discharged on January 23, 2024. A comprehensive treatment and rehabilitation plan dated November 7, 2023, indicated individual sessions weekly. Individual sessions were only documented for November 7, 17, 21, and December 5, 19, 26, 2023.
Client # 7 was admitted on October 26, 2023, and was discharged on February 16, 2024. A comprehensive treatment and rehabilitation plan developed on November 28, 2023, indicated individual sessions weekly and groups weekly. Individual sessions were only documented for January 2, 9, 16, 2024 and group sessions were only documented for December 12, 19, 22, 2023.
Client # 8 was admitted on October 4, 2023, and was discharged on March 4, 2024. A comprehensive treatment and rehabilitation plan was developed on December 19, 2023, that indicated individual sessions weekly and groups two times weekly. Group sessions were only documented for December 19, 2023, and January 9, 30, 2024.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the June 23, 2023 annual licensing inspection.
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Plan of Correction
Clinical supervisor will ensure that all staff attend documentation training by 07/31/2024.
The clinical supervisor will review client attendance which will be reviewed with all staff during clinical team meeting to discuss re-engagement.
The findings of these audits will be reviewed on an individual basis with clinicians and this review will be documented in a supervision note with feedback that will aid the clinician with the support needed to make sure that Individuals are done thoroughly. Any areas identified as needing to be fixed will be corrected within 48 hours. |
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 four of seven applicable client records reviewed, the facility failed to provide case consultations in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a case consultation to occur every ninety days.
Client # 3 was admitted on January 31, 2024, and was still active at the time of the inspection. There was no case consultation documented in the client record.
Client # 4 was admitted on September 12, 2023, and was still active at the time of the inspection. There was no case consultation documented in the client record.
Client # 5 was admitted on July 20, 2023, and was discharged on January 23, 2024. There was no case consultation documented in the client record.
Client # 8 was admitted on October 4, 2023, and was discharged on March 4, 2024. There was no case consultation documented in the client record.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the June 23, 2023, June 15, 2022, June 22, 2021, October 1, 2020, annual licensing inspections.
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Plan of Correction
Counselors will complete a weekly audit from EHR to monitor all documentation including case consultations.
The Program staff will complete a weekly self-audit of 5 charts and submit their findings to clinical supervisor. The clinical supervisor will review these audits and make necessary corrections within 48 hours
The clinical supervisor will conduct weekly case consultation meetings with Counselors to review any cases due for a consultation.
Clinical Supervisor will audit charts on a monthly basis and the division director will audit charts on a quarterly basis to ensure case consultations are completed according within program guidelines and they remain timely. The findings of these audits will be reviewed on an individual basis with clinicians and this review will be documented in a supervision note. Any areas identified as needing to be fixed will be corrected within 48 hours.
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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 three of four applicable client records reviewed, the facility failed to provide follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a follow-up to occur within seven days of referral or 30 days after discharge.
Client # 5 was admitted on July 20, 2023, and was discharged on January 23, 2024. There was no follow-up information documented in the client record.
Client # 7 was admitted on October 26, 2023, and was discharged on February 16, 2024. There was no follow-up information documented in the client record.
Client # 8 was admitted on October 4, 2023, and was discharged on March 4, 2024. There was no follow-up information documented in the client record.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the June 23, 2023, June 15, 2022, June 22, 2021, October 1, 2020, annual licensing inspection.
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Plan of Correction
Plan of Correction:
The Clinical Supervisor will run a detail of discharge report monthly that highlights when Follow-ups are completed and provide to staff.
Moving forward, the Division Director and Clinical Supervisor will adjust internal procedures for Follow-up completion. The Administrative Coordinator and counseling staff will be trained in completing Follow ups by 7/31/24.
The Clinical Supervisor will monitor the Detail of discharge report monthly to ensure that follow ups are being completed. Division Director will complete bi-monthly audits. The CQI Manager will conduct charts audits twice annually and review open plans of correction at each review. Any issues noted will be brought to the immediate attention of the clinician responsible, to be corrected within 48 hours.
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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 personnel and client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction to ensure a complete client record included information relative to the client's involvement with the project to include case consultation notes was submitted and approved by the Department for the June 23, 2023, June 15, 2022, June 22, 2021, and October 1, 2020, annual licensing inspections. Including case consultations in the client record was again found to be a deficiency in the May 16, 2024, licensing inspection.
A plan of correction to ensure a complete client record included information relative to the client's involvement with the project to include follow-up information was submitted and approved by the Department for the June 23, 2023, June 15, 2022, June 22, 2021, October 1, 2020, annual licensing inspection. Including follow-up information in the client record was again found to be a deficiency in the May 16, 2024, annual licensing inspection.
A plan of correction for ensuring staff complete the communicable disease trainings within the regulatory timeframe was submitted and approved by the Department for the June 23, 2023, and June 15, 2022, annual licensing inspection. Completing the HIV/AIDS and TB/STD trainings was again found to be a deficiency in the May 16, 2024, annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To avoid repeated citations management staff will work closely with the QA department with Gaudenzia to review files monthly and make the necessary corrections in a timely manner. Moving forward, the Clinical Supervisor will run clinical forms audit report from avatar on a weekly basis to identify areas needing additional attention.
Counseling staff will complete weekly self-audits, Clinical supervisor will complete monthly chart audits; Division Director will complete bi-monthly audits. The CQI Manager will conduct charts audits at least twice annually and review open plans of correction at each review. Any issues noted will be brought to the immediate attention of the clinician responsible, to be corrected within 48 hours.
This POC will began immediately.
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