INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 3, 2022, 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. Common Ground 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 eight personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that three employees 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 #6 was hired as a Counselor on April 22, 2020 and was due to have the communicable disease trainings no later than April 22, 2021. There was no documentation in the personnel file of the completion of the TB/STD training until June 18, 2021.
Employee #7 was hired as a counselor on April 22, 2020 and was due to have the communicable disease trainings no later than April 22, 2021. There was no documentation in the personnel file of the completion of the HIV/AIDS training until August 20, 2021 and the TB/STD training until June 18, 2021.
Employee #8 was hired as a house manager on April 20, 2020 and was due to have the communicable disease trainings no later than April 20, 2022. There was no documentation in the personnel file of the completion of the TB/STD training at the time of the inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
All staff members except one have completed the required trainings as of 5/27/22. The remaining staff member will complete these trainings by 8/31/22.
Going forward, the Program Director will review training plans for all staff members on at least a quarterly basis. Any staff members who are approaching deadlines will be scheduled to complete all required trainings prior to the required timeframe. The first of these reviews will be completed by 6/30/22
The Quality Assurance Department will conduct at least quarterly reviews of all programs, to include a review of all plans of correction to ensure full implementation.
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705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential 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 it was observed that the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the small lounge which holds clinical groups, as a camera was observed within the room and no door to the right of the room.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The camera is being removed from this area. A work order for this was submitted on 5/31/22. A partition is being installed. A work order for this was submitted on 5/29/22. An additional white noise machine was requested to be purchased on 5/29/22 These physical plant changes will be completed by 7/15/22.
In the meantime, groups will temporarily be held in an administrative room located on the first floor of the facility. This area does not contain a camera and has a door which can be closed during group sessions to ensure privacy.
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709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a review of administrative documents submitted, the project failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
The project's last annual financial audit was for the years ending June 30, 2020 and 2019.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
The Annual Financial Audit for the most recent fiscal year (FY 2020 ? 2021) was not completed in a timely manner due to the delays on the part of the independent certified public accounting firm.
Among these delays were the application of new standards regarding the review of all leased properties (to include all real estate, business machines, and vehicles). This was a very laborious process that will not need to be repeated in the future.
Gaudenzia will obtain a completed financial audit from the independent certified public accounting firm on or before September 30th of 2022.
In order to help ensure that these delays do not occur in the future, the reorganized Fiscal department will begin preparation of all possible documents required for the audit as early as possible in the year.
Leadership in this department reviewed the regulations in DDAP 709.25 on 4/26/22 in order to ensure that all understand the importance of timely completion of the Financial Audit.
The Chief Financial Officer will oversee this process.
9/30/22
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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 fourteen client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in one client records reviewed,
Client #1 was admitted on March 8, 2022 and was still active at the time of the inspection. There was documentation that a report was made to the funding source on April 28, 2022, and April 21, 2022; however, there was no informed and voluntary consent to release information form signed by the client prior to disclosure.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
After review of Client #1 chart who is still active in the program, a consent to release information for the current funding source was added to the Electronic Health Record on 5/3/22.
In addition, staff are scheduled for an in-service training on 6/1/22 which will be conducted by the Clinical Supervisor regarding how to properly document release of information in the record. This training will include detailed handouts containing 'screen-shots' of the electronic forms in order to ensure that all staff understand exactly where and how to document this, and the specific limits to what can be released.
The Clinical Supervisor will conduct weekly audits of a sample of clinical charts in order to ensure that consent forms are properly completed in all charts. These audits will be documented using the standard audit tools developed for this purpose. Any missing or incorrect documentation will be brought to the attention of the clinician and addressed within 48 hours.
The Acting Program Director will conduct monthly audits of a sample of charts in order to ensure that consent forms are properly completed in all charts. These audits will be documented using the standard audit tools developed for this purpose. Any missing or incorrect documentation will be brought to the attention of the Clinical Supervisor in order to follow up with the clinician in supervision and be completed/corrected within 48 hours.
The Quality Assurance Department will conduct at least quarterly audits, to include consent forms as well as all Plans of Correction to ensure full implementation. These audits will be documented using the standard audit tools developed for this purpose.
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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 a review of fourteen client records, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in one client record reviewed.
Client #3 was admitted on March 28, 2022 and was an active client as of the date of the inspection. An informed and voluntary consent to release information form was signed and dated on March 17, 2022 to the funding source that allowed for the release of medication records.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Client #3 discharge from treatment on 5/11/22. An updated release of information for the funding source was updated on 5/3/22 to reflect only the 5 areas of disclosures under Pa. Code 255.5 (b).
Staff are scheduled for an in-service training on 6/1/22 which will be conducted by the Clinical Supervisor regarding how to properly document release of information in the record. This training will include detailed handouts containing 'screen-shots' of the electronic forms in order to ensure that all staff understand exactly where and how to document this, and the specific limits to what can be released.
The Clinical Supervisor will conduct weekly audits of a sample of charts in order to ensure that consent forms are properly completed in all charts. These audits will be documented using the standard audit tools developed for this purpose. Any missing or incorrect documentation will be brought to the attention of the clinician and addressed within 48 hours.
The Acting Program Director will conduct monthly audits of a sample of charts in order to ensure that consent forms are properly completed in all charts. These audits will be documented using the standard audit tools developed for this purpose. Any missing or incorrect documentation will be brought to the attention of the Clinical Supervisor in order to follow up with the clinician in supervision and be completed/corrected within 48 hours.
The Quality Assurance Department will conduct at least quarterly audits, to include consent forms as well as all Plans of Correction to ensure full implementation. These audits will be documented using the standard audit tools developed for this purpose.
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