INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 12, 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. 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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709.92(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 document treatment plan updates within the regulatory timeframe in three out of seven client records reviewed.Client #1 was admitted on April 28, 2022 and was still active at the time of the inspection. A treatment plan was completed on June 14, 2022 and the treatment plan update was due no later than August 14, 2022; however the treatment plan update was completed on August 22, 2022. Client #4 was admitted on April 18, 2022 and was still active at the time of the inspection. A treatment plan was completed on June 6, 2022 and the treatment plan update was due no later than August 6, 2022; however, the treatment plan update was completed on August 11, 2022. Client #6 was admitted on February 22, 2022 and was discharged on June 21, 2022. A treatment plan was completed on March 22, 2022 and the treatment plan update was due no later than May 22, 2022; however, the treatment plan update was completed on June 21, 2022.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervision sessions will be held with each clinician no later than 10/14/22 to address treatment management procedures specific to the treatment plan update process.
All staff will be directed to update treatment plans at least every 30 days for IOP and 60 days for OP. Should the client not attend the scheduled session to develop treatment plans as scheduled, clinical staff will proceed to update the plan as appropriate and document that the plan will be reviewed with the client during the next attended session and updated as needed at that time.
The Clinical Supervisor and Division Director will review treatment plans for compliance during monthly audits. This will be reviewed with Clinical staff in documented regular supervisory sessions. Any outstanding items will be corrected/completed within 48 hours.
The Quality Assurance department will complete at least quarterly reviews, to include audits of treatment plan updates for completion. Any issues noted in this area will result in the development of a performance improvement plan.
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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 a review of client records, the facility failed to document case consultations according to the facility's written policy and procedure manual in four out of seven records reviewed. The facility's policy manual indicated case consultations would be documented every ninety days after the client is admitted to treatment. Client #1 was admitted on April 28, 2022 and was still active at the time of the inspection. A case consult was due no later than July 28, 2022; however, client #1 did not have a case consult completed at the time of the inspection. Client #2 was admitted on April 25, 2022 and was still active at the time of the inspection. A case consult was due no later than July 25, 2022; however, client #2 did not have a case consult completed at the time of the inspection.Client #4 was admitted on April 18, 2022 and was still active at the time of the inspection. A case consult was due no later than July 18, 2022; however, client #4 did not have a case consult completed at the time of the inspection.Client #7 was admitted on August 31, 2021 and was discharged on March 3, 2022. A case consult was due no later than November 30, 2021; however it was completed on January 28, 2022. These findings were reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervision sessions will be held with each clinician no later than 10/14/22 to the case consultation update process.
All active clients will have case consultations completed within 90 days, or at least once during treatment if the course of treatment is expected to be less than 90 days.
Counselors and Clinical Supervisor will meet on a weekly basis to complete case consultations regarding the individuals for whom one is due that week. During these meetings, clinicians discuss the overall progress or concerns regarding each client. The primary counselor is responsible for completing the case consultation documentation. This documentation is to include the date of consult, names of attending staff and titles, client name, summary of discussion and disposition of case reviewed. The case consult will be signed by the primary counselor and reviewed for thoroughness and completeness and routed to the Clinical Supervisor and any other clinician involved in the discussion for signatures.
The Clinical Supervisor and Division Director will review case consultation notes for compliance during monthly audits. This will be reviewed with Clinical staff in documented regular supervisory sessions. Any outstanding items will be corrected/completed within 48 hours.
The Quality Assurance department will complete at least quarterly reviews, to include audits of case consultation documentation for completion. Any issues noted in this area will result in the development of a performance improvement plan.
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