INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 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 Washington House 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(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of one applicable record.
Employee # 3 has been in the position of counselor since March 4, 2013. The facility's training year that was reviewed was from January 2022 through December 2022. Employee # 3's personnel record only documented 12.75 hours of training for the period reviewed.
This is a repeat citation from the May 26, 2022 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will ensure all training hours are completed within required timeframes and according to annual training plan for each employee.
Program Director will run the training report on a quarterly basis for all staff and document in a supervision note to ensure staff nearing the deadlines for training completion will complete scheduled training prior to the due date.
CQI manager will review staff trainings in Relias during quarterly program audits to ensure all staff are up to date on required trainings and hours. All completed hours and any training that is due by the next quarterly audit will be reported to the Program Director for follow up. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of four personnel records, the facility failed to ensure that each staff was instructed in the use of the fire extinguishers upon employment in one applicable record reviewed.
Employee # 4 was hired as a support staff member on September 12, 2022 and was due to be trained in the use of fire extinguishers upon employment; however, fire safety training was not documented as complete until April 19, 2023.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #4 did receive Fire Safety as part of the CARF Training that was completed and documented.
Program Director will ensure all new employees attend CARF training during orientation and annually thereafter by running the training report through Relais on a quarterly basis. The Program Director will document this information in a supervision note to ensure that all staff understand what training hours they still need to be in compliance. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of seven client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients in two of two applicable records reviewed.
Client # 2 was admitted on October 27, 2022 and was discharged Against Staff Advice (ASA) on November 19, 2022. The facility failed to follow their policy related to ASA discharges of calling the Emergency Contact within twelve hours.
Client # 4 was admitted on February 17, 2023 and was discharged Against Staff Advice (ASA) on March 27, 2023. The facility failed to follow their policy related to ASA discharges of calling the Emergency Contact within twelve hours.
This is a repeat citation from the May 26, 2022 annual licensing inspection.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
Should a client leave the program Against Staff Advice, the primary counselor will notify the Emergency Contact within 12 hours. If the primary counselor is not present, the Recovery Support Professional will be responsible to notify the Emergency Contact. In all cases, an Emergency Contact follow up note will be completed in the client's chart.
The Program Director will review the policy with all staff in an in-service training no later than 7/14/2023. Program Director will run the Detail of Discharges by Program report 3x weekly to ensure all clients who left against staff advice had the emergency contact follow up note completed. If it was not completed, the Program Director will complete the follow up call and document it in the client's chart. |
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 seven 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 # 4 was admitted on February 17, 2023 and was discharged on March 27, 2023. The consent to release information form to the funding source was not signed until February 24, 2023, and there was evidence of billing prior to the client signed consent to release information form.
This is a repeat citation from the May 26, 2022, and June 10, 2021 annual licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All current staff members with responsibility for completion of releases will be scheduled to attend the web-based Drug and Alcohol Confidentiality Training facilitated by DDAP. This will be completed by 8/1/2023. Staff members will also attend the Release/Request training facilitated by the CQI department at Gaudenzia by 8/15/2023.
All new client charts will be reviewed by the Program Director to ensure proper releases are completed at admit, including the funding source. The Program Director will develop a chart review form by 7/14/2023 that will include releases of information to document the chart review findings. These audits will be shared with the clinical staff during weekly supervision. Any missing or incomplete releases will be completed with the client within 24 hours by clinician |
709.52(c) LICENSURE Provision of Counseling Services
709.52. 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 plans in three of seven applicable records reviewed.
Client # 1 was admitted on December 20, 2022 and was discharged on April 11, 2023. The treatment plans completed on February 18, 2023, and April 9, 2023, indicated that the client was to receive one individual session per week; however, the record contained no documentation of an individual session between February 16, 2023, and March 15, 2023, or between March 17, 2023, and the date of discharge.
Client # 3 was admitted on August 3, 2022 and was discharged on November 19, 2022. The treatment plans completed on September 3, 2022, and October 2, 2022, indicated that the client was to receive one individual session per week; however, the record contained no documentation of individual sessions between September 27, 2022 and October 19, 2022.
Client # 4 was admitted on February 17, 2023 and was discharged on March 27, 2023. The treatment plan completed on March 22, 2023, indicated that the client was to receive one individual session per week; however, the record contained no documentation of individual sessions between February 26, 2023 and March 16, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will complete weekly Chart Audits to ensure that client services are being provided as identified by their treatment plan. The Program Director will develop a review form by 7/14/2023 to document the chart review findings regarding note documentation based on the client's treatment plan. These audits will be shared with the clinical staff during weekly supervision.
Program Director will review the audit finding during weekly supervision.
Program Director will review with the clinical staff clinical necessity of following the treatment plan regarding treatment services by 7/14/2023. |
709.53(a)(10) LICENSURE Discharge Summary
709.53. 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 and the facility ' s policies and procedures, 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 within seven days of discharge, in two of four applicable records reviewed.
Client # 2 was admitted on October 27, 2022 and was discharged on November 19, 2022. The discharge summary was not completed until December 9, 2022.
Client # 4 was admitted on February 17, 2023 and was discharged on March 27, 2023. There was no documentation of a discharge summary in the record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Primary Counselor is responsible for completing discharge information for assigned clients. Program Director will monitor all discharges to ensure that discharge summary has been completed and submitted in the EHR within 7 days of discharge. Program Director will review all client files at time of discharge to ensure that this has been completed.
Program Director will review missing discharge information with the counselor who will have 48 hours to complete. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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.
Client # 1 was admitted on December 20, 2022 and was discharged on April 11, 2023. There was no documentation of follow-up information in the record.
Client # 2 was admitted on October 27, 2022 and was discharged on November 19, 2022. There was no documentation of follow-up information in the record.
Client # 3 was admitted on August 3, 2022 and was discharged on November 19, 2022. There was no documentation of follow-up information in the record.
Client # 4 was admitted on February 17, 2023 and was discharged on March 27, 2023. There was no documentation of follow-up information in the record.
This is a repeat citation from the May 26, 2022 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will ensure that Follow up contact notes are completed and submitted by assigned counselor within 7 days of Aftercare appointment or within 30 days of discharge if the client declined a referral at discharge, in accordance with Gaudenzia's Policy and Procedures.
Staff will be retrained on the follow-up procedure in an in-service training by Program Director no later than 7-14-2023. Program Director will run the Detail of Discharges by Program report on a weekly basis which indicates if a follow-up note has been completed or not. Program Director will review this information during weekly clinical supervision.
The Administrative Coordinator will be responsible to run a detail of Discharge Report from our EHR noting which clients require a follow-up contact. This list will be brought to the weekly clinical meeting as a reminder to the clinical staff to complete this action step. |
709.53(a)(12) LICENSURE Work as treatment
709.53. 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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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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 verification that any work done by the client at the project is an integral part of his/her treatment and rehabilitation plan in two of six applicable client records reviewed.
Client # 3 was admitted on August 3, 2022 and was discharged on November 19, 2022.
Client # 5 was admitted on March 9, 2023 and was active at the time of the inspection.
This is a repeat citation from the May 26, 2022 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Work as treatment will be identified on all Treatment Plans as a Therapeutic Activities of Daily Living goal/ Counselor will identify and update work therapy assigned to the client as integral part of their treatment plan. Program Director will continue to conduct chart and clinical documentation review to ensure that this is included in Treatment Plan.
The Program Director will develop a chart audit review form by 7/14/2023 to document whether these activities are identified on the client's Treatment Plan and to ensure they are appropriate to the client. |
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 and personnel records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for obtaining client signed consent to release information forms prior to disclosures of information was submitted and approved by the Department for the May 26, 2022, and June 10, 2021, annual licensing inspections. Obtaining client signed consent to release information forms prior to disclosing information was again found to be a deficiency in the June 12, 2023, licensing inspection.
A plan of correction for calling client emergency contacts within 12 hours of an Against Staff Advice discharge was submitted and approved by the Department for the May 26, 2022, annual licensing inspection. Contacting emergency contacts was again found to be a deficiency in the June 12, 2023, licensing inspection.
A plan of correction for including follow-up information in the client record was submitted and approved by the Department for the May 26, 2022, annual licensing inspection. Completing follow-up information was again found to be a deficiency in the June 12, 2023, licensing inspection.
A plan of correction for including verification of work therapy in the individual treatment and rehabilitation plan was submitted and approved by the Department for the May 26, 2022, annual licensing inspection. Verification of work therapy on the individual treatment plans was again found to be a deficiency in the June 12, 2023, licensing inspection.
A plan of correction for ensuring counselors obtained 25 hours of training per training year was submitted and approved by the Department for the May 26, 2022, annual licensing inspection. The completion of 25 hours of training for counselors was again found to be a deficiency in the June 12, 2023, licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Ultimately the Program Director will be responsible for implementation of all Plan of Correction Items.
The Program Director will complete monthly reviews of all POC items to ensure that they have been and continue to be implemented. Any issues noted will be addressed with the appropriate party in a documented supervision session and corrected within 48 hours. In addition, the Quality Assurance department will conduct quarterly audits of the program, which include reviews of any open POCs. Any issues noted will be brought to the immediate attention of the Program Director to be addressed as noted above. |