INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 9, 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. 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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709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records, the facility failed to ensure that annual written individual staff performance evaluations, were reviewed and signed by the employee per the facility's policy and procedure manual in three out of five personnel records reviewed. The facility's policy and procedure manual states that the annual job performance evaluations are due at the beginning of each calendar year. Project staff indicated evaluations specifically are to be completed and signed by February 1 each year.
Employee #1 was hired on September 9, 2019 as the project director and is still in that position at the time of the inspection The annual work performance evaluation was not completed until February 28, 2024.
Employee # 4 was hired on April 26, 2011 as a counselor and is still in that position at the time of the inspection. The annual work performance evaluation was not completed until February 2, 2024.
Employee #5 was hired on April 18, 2022 as a counselor and was still in that position at the time of the inspection. The annual work performance was not competed until February 20, 2024.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
By May 10, 2024, Division Director will speak to the Clinical Supervisors at all programs to let them know the expectation is to review the annual reviews with all staff one week prior to 1/31/25. The Division Director will further review the expectation is after they are discussed with the staff, to have the staff immediately sign into their ADP to sign off on their review and write any applicable comments. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on the review of the client records, the facility failed to document a medical history, as per the facility ' s policy and procedure manual in six out of seven client records. The facility ' s policy and procedures manual states histories are completed at the intake process.
Client #2 completed the intake process from September 8, 2023 through September 26, 2023. The client was admitted on September 26, 2023 and was still active at the time of the inspection. A medical history was due no later than September 26, 2023; however, was not completed until November 10, 2023.
Client #3 completed the intake process from December 4, 2023 through December 20,2023. The client was admitted on December 20, 2023 and was still active at the time of the inspection. A medical history was due no later than December 20, 2023; however, was not completed until December 24, 2023.
Client #4 completed the intake process from August 9, 2023 through August 17, 2023. The client was admitted on August 17, 2023 and discharged on September 14, 2023. There was no documentation of a medical history.
Client #5 completed the intake process from July 25, 2023 through July 26, 2023. The client was admitted on July 26, 2023 and discharged on August 16, 2023. There was no documentation of a medical history.
Client #6 completed the intake process from July 11, 2023 through July 11, 2023. The client was admitted on July 11, 2023 and was discharged on September 7, 2023. There was no documentation of a medical history.
Client #7 completed the intake process from November 29, 2023 through December 7, 2023. The client was admitted on December 8, 2023 and was still active at the time of the inspection. The medical history was due no later than December 7, 2023; however, was not completed until January 11, 2024.
This is a repeat citation from the June 21, 2023 licensing inspection.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
By May 10, 2024, the Clinical Supervisor will review the workflow with the counselors, and counselors will be required to use it and submit it to the Clinical Supervisor weekly for verification of the completion of the required documentation including the medical histories for the next 60 days. Should the counselor not follow this plan corrective action will be taken against the counselor as per the disciplinary policy. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on the review of the client records, the facility failed to document a drug and alcohol history, as per the facility ' s policy and procedure manual in six out of seven client records. The facility ' s policy and procedure manual states histories are completed at the intake process.
Client #2 completed the intake process from September 8, 2023 through September 26, 2023. The client was admitted on September 26, 2023 and was still active at the time of the inspection. A drug and alcohol history was due no later than September 26, 2023; however, was not completed until November 10, 2023.
Client #3 completed the intake process from December 4, 2023 through December 20,2023. The client was admitted on December 20, 2023 and was still active at the time of the inspection. A drug and alcohol history was due no later than December 20, 2023; however, was not completed until December 24, 2023.
Client #4 completed the intake process from August 9, 2023 through August 17, 2023. The client was admitted on August 17, 2023 and discharged on September 14, 2023. There was no documentation of a drug and alcohol history.
Client #5 completed the intake process from July 25, 2023 through July 26, 2023. The client was admitted on July 26, 2023 and discharged on August 16, 2023. There was no documentation of a drug and alcohol history.
Client #6 completed the intake process from July 11, 2023 through July 11, 2023. The client was admitted on July 11, 2023 and was discharged on September 7, 2023. There was no documentation of a drug and alcohol history.
Client #7 completed the intake process from November 29, 2023 through December 7, 2023. The client was admitted on December 8, 2023 and was still active at the time of the inspection. The drug and alcohol history was due no later than December 7, 2023; however, was not completed until January 11, 2024.
This is a repeat citation from the June 21, 2023 licensing inspection.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
By May 10, 2024, the Clinical Supervisor will review the workflow with the counselors, and counselors will be required to use it and submit it to the Clinical Supervisor weekly for verification of the completion of the required documentation including the medical histories for the next 60 days. Should the counselor not follow this plan corrective action will be taken against the counselor as per the disciplinary policy.
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709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on the review of the client records, the facility failed to document a personal history, as per the facility ' s policy and procedure manual in six out of seven client records. The facility ' s policy and procedure manual states histories are completed at the intake process.
Client #2 completed the intake process from September 8, 2023 through September 26, 2023. The client was admitted on September 26, 2023 and was still active at the time of the inspection. A personal history was due no later than September 26, 2023; however, was not completed until November 10, 2023.
Client #3 completed the intake process from December 4, 2023 through December 20,2023. The client was admitted on December 20, 2023 and was still active at the time of the inspection. A personal history was due no later than December 20, 2023; however, was not completed until December 24, 2023.
Client #4 completed the intake process from August 9, 2023 through August 17, 2023. The client was admitted on August 17, 2023 and discharged on September 14, 2023. There was no documentation of a personal history.
Client #5 completed the intake process from July 25, 2023 through July 26, 2023. The client was admitted on July 26, 2023 and discharged on August 16, 2023. There was no documentation of a personal history.
Client #6 completed the intake process from July 11, 2023 through July 11, 2023. The client was admitted on July 11, 2023 and was discharged on September 7, 2023. There was no documentation of a personal history.
Client #7 completed the intake process from November 29, 2023 through December 7, 2023. The client was admitted on December 8, 2023 and was still active at the time of the inspection. The personal history was due no later than December 7, 2023; however, was not completed until January 11, 2024.
This is a repeat citation from the June 21, 2023 licensing inspection.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
By May 10, 2024, the Clinical Supervisor will review the workflow with the counselors, and counselors will be required to use it and submit it to the Clinical Supervisor weekly for verification of the completion of the required documentation including the medical histories for the next 60 days. Should the counselor not follow this plan corrective action will be taken against the counselor as per the disciplinary policy. |
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 the review of client records, the facility failed to document a complete psychosocial evaluation per the facility ' s policy and procedure manual in five out of five applicable records. The facility ' s policy states a psychosocial evaluation is completed within thirty days of admission.
Client #1 was admitted on October 10, 2023 and was still active at the time of the inspection. There was no documentation of a psychosocial evaluation.
Client #2 was admitted on September 26, 2023 and was still active at the time of the inspection. There was no documentation of a psychosocial evaluation.
Client #3 was admitted on December 20, 2023 and was still active at the time of the inspection. There was no documentation of a psychosocial evaluation.
Client #6 was admitted on July 11, 2023 and was discharged on September 7, 2023. There was no documentation of a psychosocial evaluation.
Client #7 was admitted on December 8, 2023 and was still active at the time of the inspection. There was no documentation of a psychosocial evaluation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By May 10, 2024, the Clinical Supervisor will review the workflow with the counselors, and counselors will be required to use it and submit it to the Clinical Supervisor weekly for verification of the completion of the required documentation including the medical histories for the next 60 days. Should the counselor not follow this plan corrective action will be taken against the counselor as per the disciplinary policy.
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709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of the client records, the facility failed to document a comprehensive treatment plan within guidelines established by the facility ' s policy and procedure manual in two out of five applicable records reviewed. The facility ' s policy and procedure manual states the comprehensive treatment plan must be completed within 30 days of admission.
Client #1 was admitted on October 10, 2023 and was still active at the time of the inspection. The comprehensive treatment plan was due no later than November 10, 2023; however, there is no documentation that one was completed.
Client #6 was admitted on July 11, 2023 and was discharged on September 7, 2023. A comprehensive treatment plan was due no later than August 11, 2023; however, there is no documentation that one was completed.
This is a repeat citation from the June 21, 2023 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Starting May 3, 2024, the Clinical Supervisor will run the treatment plan analysis report on a weekly basis and send emails out to counselors of treatment plans that are due or coming due. Clinical Supervisor is responsible with making sure these are completed by the counselors. Failure by counselors to complete these treatment plans in a timely fashion will result in disciplinary action. |
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 within the timeframe established by the facility ' s policy and procedure manual in six out of seven applicable client records. The facility's policy and procedure manual states case consultations are completed every ninety days unless the client ' s treatment is less than ninety then one is completed.
Client #1 was admitted on October 10, 2023 and was still active at the time of the inspection. A case consultation was due no later than January 10, 2024; however, there is no documentation that one was completed.
Client #3 was admitted on December 20, 2023 and was still active at the time of the inspection. A case consultation was due no later than March 20, 2024; however, there is no documentation that one was completed.
Client #4 was admitted on August 17, 2023 and discharged on September 14, 2023. A case consultation was to be completed prior to discharge if the client was only in treatment less than 90 days, there is no documentation that one was completed.
Client #5 was admitted on July 26, 2023 and discharged on August 16, 2023. A case consultation was to be completed prior to discharge if the client was only in treatment less than 90 days, there is no documentation that one was completed.
Client #6 was admitted on July 11, 2023 and was discharged on September 7, 2023. A case consultation was to be completed prior to discharge if the client was only in treatment less than 90 days, there is no documentation that one was completed.
Client #7 was admitted on December 8, 2023 and was still active at the time of the inspection. A case consultation was due no later than March 8, 2024; however, there is no documentation that one was completed.
This is a repeat citation from the June 21, 2023 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning May 3, 2024, the Clinical Supervisor will run the Clinical Forms Audit report monthly and send out emails to all staff of case consultations coming due. The Clinical Supervisor will ensure that these case consults are completed. Failure by counselors to complete these treatment plans in a timely fashion will result in disciplinary action. |
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 a review of client records, the facility failed to provide a complete client record on an individual which includes information relative to the client's involvement with the project, including a discharge summary in three of three applicable records. The facility's policy and procedure manual states that a discharge summary is completed within seven days of discharge.
Client #4 was admitted on August 17, 2023 and discharged on September 14, 2023. A discharge summary was due no later than September 21, 2023; however, there is no documentation that one was completed.
Client #5 was admitted on July 26, 2023 and discharged on August 16, 2023. A discharge summary was due no later than August 23, 2023; however, there is no documentation that one was completed.
Client #6 was admitted on July 11, 2023 and was discharged on September 7, 2023. A discharge summary was due no later than September 14, 2023; however, there is no documentation that one was completed.
This is a repeat citation from the June 21, 2023 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Starting May 10, 2024 Clinical Supervisor will run the discharge analysis report weekly and send emails to counselors of outstanding discharge paperwork. After the staff meeting on May 10th, counselors will be given one hour of paperwork time dedicated to discharge paperwork per week that must be completed |