INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on December 22, 2020 through December 23, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated 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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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 the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in three of fourteen client records reviewed.
Client #3 was admitted on September 13, 2020 and was discharged on October 16, 2020. There was documentation of two family members participating in a family therapy session with the client on October 7, 2020; however, there was no release of information form documented in the client's record.
Client #5 was admitted on March 25, 2020 and was discharged on May 5, 2020. There was documentation of communication between the facility and a recovery house on April 14, 2020 and May 4, 2020: however, there was no release of information form documented in the client ' s record.
Client #12 was admitted on March 18, 2020 and was discharged on April 16, 2020. There was no release of information form for the funding source documented in the client ' s record.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The project maintains a policy that requires staff to obtain an informed and voluntary consent from all clients for disclosure of information.
The project will conduct an in-service with clinical staff to reinforce this policy with staff.
The Clinical Supervisor shall monitor compliance with this policy by conducting monthly file audits. These audits will be reviewed with staff during monthly supervisions.
The CQI Manager will further monitor compliance with this policy by conducting quarterly file audits. results of this audit will be shared with the Program Director and Clinical Supervisor.
In addition, the items in this Plan of Correction will be monitored by Corporate Compliance to ensure compliance. |
709.28 (c) (2) 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. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on the review of client records, the project failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in six of fourteen client records reviewed.
Client #1 was admitted on November 16, 2020 and was an active client at time of inspection. Two release of information forms to a funding source, signed and dated by the client on November 17, 2020 and November 23, 2020, allowed for the release of psychological and psychiatric evaluations, treatment plans, case consults, mental health records, physical and medical records, discharge summary, progress notes, medication records and assessments, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #3 was admitted on September 13, 2020 and was discharged on October 16, 2020. A release of information form to a funding source, signed and dated by the client on September 19, 2020, allowed for the release of psychological and psychiatric evaluations, treatment plans, case consults, mental health records, physical and medical records, discharge summary, progress notes, medication records and assessments, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #4 was admitted on September 9, 2020 and was discharged November 16, 2020. A release of information form to a funding source, signed and dated by the client on October 31, 2020, allowed for the release of psychological and psychiatric evaluations, treatment plans, case consults, mental health records, physical and medical records, discharge summary, progress notes, medication records and assessments, all of which exceeds the limits established by 4 Pa. Code 255.5. Additionally, a release of information form to a county probation agency, signed and dated by the client on November 5, 2020, allowed for the release of psychological and psychiatric evaluations, treatment plans, case consults, mental health records, physical and medical records, discharge summary, progress notes, medication records and assessments.
Client #7 was admitted on November 20, 2020 and was discharged on December 15, 2020. A release of information form to a funding source, signed and dated by the client on November 20, 2020, allowed for the release of psychological and psychiatric evaluations, treatment plans, case consults, mental health records, physical and medical records, discharge summary, progress notes, medication records and assessments, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #8 was admitted on November 18, 2020 and was an active client at the time of the inspection. A release of information form to a funding source, signed and dated by the client on November 23, 2020, allowed for the release of psychological and psychiatric evaluations, treatment plans, case consults, mental health records, physical and medical records, discharge summary, progress notes, medication records and assessments, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #9 was admitted on December 2, 2020 and was an active client at the time of the inspection. A release of information form to a funding source, signed and dated by the client on December 3, 2020, allowed for the release of psychological and psychiatric evaluations, treatment plans, case consults, mental health records, physical and medical records, discharge summary, progress notes, medication records and assessments, all of which exceeds the limits established by 4 Pa. Code 255.5.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The project maintains a policy that requires staff to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information.
Project Director and/or designee will review all active client files to ensure that releases of information are in compliance with 4 PA. Code 255.5 by 01/29/2021.
The project will conduct an in-service with clinical staff to reinforce this policy with staff.
The Clinical Supervisor shall monitor compliance with this policy by conducting monthly file audits. These audits will be reviewed with staff during monthly supervisions.
The CQI Manager will further monitor compliance with this policy by conducting quarterly file audits. Results of this audit will be shared with the Program Director and Clinical Supervisor. The results of CQI audits will also be shared during monthly CQI meetings with Leadership.
The items in this Plan of Correction will be monitored by Corporate Compliance to ensure compliance. |
709.28 (c) (6) 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. The consent must be in writing and include, but not be limited to:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included a date, event or condition upon which the consent will expire in one of fourteen client records reviewed.
Client #5 was admitted on March 25, 2020 and was discharged on May 5, 2020. Three signed release of information forms documented in the client record, two for government agencies and one for an emergency contact, did not document a date, event or condition upon which the consent would expire.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The project maintains a policy that requires staff to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that includes a date, event or condition upon which the consent will expire.
The project will conduct an in-service with clinical staff to reinforce this policy with staff.
The Clinical Supervisor shall monitor compliance with this policy by conducting monthly file audits. These audits will be reviewed with staff during monthly supervisions.
The CQI Manager will further monitor compliance with this policy by conducting quarterly file audits. Results of this audit will be shared with the Program Director and Clinical Supervisor. The results of CQI audits will also be shared during monthly CQI meetings with Leadership.
The items in this Plan of Correction will be monitored by Corporate Compliance to ensure compliance. |
709.51(b)(7) LICENSURE Preliminary Tx. Plan.
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on the review of client records, the project failed to document a preliminary treatment and rehabilitation plan at intake in six of fourteen client records reviewed.
Client #1 was admitted on November 16, 2020 and was an active client at time of inspection. A preliminary treatment plan was not documented in the client record until November 25, 2020.
Client #2 was admitted on December 13, 2020 and was an active client at the time of the inspection. A preliminary treatment plan was not documented in the client record.
Client #4 was admitted on September 9, 2020 and was discharged November 16, 2020. A preliminary treatment plan was not documented in the client record until September 17, 2020.
Client #7 was admitted on November 20, 2020 and was discharged on December 15, 2020. A preliminary treatment plan was not documented in the client record until November 29, 2020.
Client #8 was admitted on November 18, 2020 and was an active client at the time of the inspection. A preliminary treatment plan was not documented in the client record until November 29, 2020.
Client #10 was admitted on November 27, 2020 and was discharged on December 15, 2020. A preliminary treatment plan was not documented in the client record.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The project maintains a policy that requires staff to document a preliminary treatment plan within 5 days of admission to the site.
The project will conduct an in-service with clinical staff to reinforce this policy with staff.
The Clinical Supervisor shall monitor compliance with this policy by conducting monthly file audits. These audits will be reviewed with staff during monthly supervisions.
The CQI Manager will further monitor compliance with this policy by conducting quarterly file audits. Results of this audit will be shared with the Program Director and Clinical Supervisor. The results of CQI audits will also be shared during monthly CQI meetings with Leadership.
The items in this Plan of Correction will be monitored by Corporate Compliance to ensure compliance. |
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 the review of client records, the project failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan in six of fourteen client records reviewed.
Client #1 was admitted on November 16, 2020 and was an active client at time of inspection. A comprehensive treatment plan completed on November 25, 2020, indicated that the client was to receive one individual counseling session and four group counseling sessions per week. There were no individual counseling sessions documented for this client for the weeks of November 22, 2020 through November 28, 2020 and November 29, 2020 through December 5, 2020.
Client #4 was admitted on September 9, 2020 and was discharged November 16, 2020. A comprehensive treatment plan completed on September 17, 2020, indicated that the client was to receive one individual counseling session and four group counseling sessions per week. There were no individual counseling sessions documented for this client for the week of September 27, 2020 through October 3, 2020.
Client #5 was admitted on March 25, 2020 and was discharged on May 5, 2020. A comprehensive treatment plan completed on March 31, 2020, indicated that the client was to receive one individual counseling session and three group counseling sessions per week. There were no individual counseling sessions documented for this client for the week of April 26, 2020 through May 2, 2020.
Client #10 was admitted on November 27, 2020 and was discharged on December 15, 2020. A comprehensive treatment plan completed on December 9, 2020, indicated that the client was to receive one individual counseling session and four group counseling sessions per week. There were no individual counseling sessions documented for this client for the week of December 6, 2020 through December 12, 2020.
Client #13 was admitted on July 28, 2020 and was discharged on August 27, 2020. A comprehensive treatment plan completed on July 30, 2020, indicated that the client was to receive one individual counseling session and four group counseling sessions per week. There were no individual counseling sessions documented for this client for the week of August 2, 2020 through August 8, 2020.
Client #14 was admitted on August 26, 2020 and was discharged on September 24, 2020. A comprehensive treatment plan completed on August 31, 2020, indicated that the client was to receive one individual counseling session and four group counseling sessions per week. There were no individual counseling sessions documented for this client for the week of September 13, 2020 through September 19, 2020.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The project maintains a policy that requires counseling services to be provided in accordance with the client's plan.
The project will conduct an in-service with clinical staff to reinforce this policy.
The Clinical Supervisor shall monitor compliance with this policy by conducting monthly file audits. These audits will be reviewed with staff during monthly supervisions.
The CQI Manager will further monitor compliance with this policy by conducting quarterly file audits. Results of this audit will be shared with the Program Director and Clinical Supervisor. The results of CQI audits will also be shared during monthly CQI meetings with Leadership.
The items in this Plan of Correction will be monitored by Corporate Compliance to ensure compliance. |
709.53(a)(8) LICENSURE Case Consultation Notes
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:
(8) Case consultation notes.
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Observations
Based on the review of client records, the project failed to ensure that there was a complete client record on an individual's involvement with the project that included case consultation notes in four of fourteen client records reviewed.
Client #5 was admitted on March 25, 2020 and was discharged on May 5, 2020. There were no case consultation notes documented in the client record.
Client #6 was admitted on September 30, 2020 and was discharged on November 5, 2020. There were no case consultation notes documented in the client record.
Client #11 was admitted on February 14, 2020 and was discharged on March 16, 2020. There were no case consultation notes documented in the client record.
Client #14 was admitted on August 26, 2020 and was discharged on September 24, 2020. There were no case consultation notes documented in the client record.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The project maintains a policy that requires the site to conduct case consultations within 15 days of admission and every 30 days thereafter. In addition, this policy requires the site to maintain a complete client record on an individual's involvement with the project.
The project will conduct an in-service with clinical staff to reinforce this policy.
The Clinical Supervisor shall monitor compliance with this policy by conducting monthly file audits. These audits will be reviewed with staff during monthly supervisions.
The CQI Manager will further monitor compliance with this policy by conducting quarterly file audits. Results of this audit will be shared with the Program Director and Clinical Supervisor. The results of CQI audits will also be shared during monthly CQI meetings with Leadership.
The items in this Plan of Correction will be monitored by Corporate Compliance to ensure compliance. |