INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 21, 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. Kindred 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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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 of the counseling room as cameras were operating in the group counseling rooms located in the basement and the upper level of the building.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Gaudenzia has been granted a DDAP exception waiver to 705.4 (3) allowing video-only recording strictly for safety and security purposes in the common areas of the program, including areas which may be used for group sessions. This exception waiver was granted as of 6/18/24.
Gaudenzia is adding language to our consent forms to obtain informed consent from all clients to allow video-only recording strictly for safety and security purposes in the common areas of the program, including areas which may be used for group sessions. This language will be added to the consent forms no later than 6/30/24 and will then be reviewed and signed by all current clients prior to their next counseling session.
In the interim, the program will disable any camera which is positioned in such a way as to capture video of any counseling session. These cameras will be enabled once all clients have signed the consents, no later than 7/12/24.
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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 two 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 #5 was hired on October 28, 2019 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 13, 2024.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
All Gaudenzia Managers will ensure that Annual Performance Evaluations are completed, reviewed with the employee during a documented supervision session, and acknowledged via signature by both parties no later than February 1st of each year.
The Chief Executive Officer will ensure that this process is completed for the Project Director.
The Deputy Directors will ensure that this process is completed for all Division Directors.
The Division Directors will complete Annual Performance Evaluations for each of the Program Directors that they oversee, and will also ensure that these Program Directors complete Annual Performance Evaluations for the staff that they oversee.
The Quality Assurance department will review staff files during semi-annual program reviews to ensure compliance.
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709.28 (a) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
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Observations
Based on a review of records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in two out of seven records reviewed.
Client #5 was admitted on August 7, 2023 and discharged on September 1, 2023. There was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the insurance was billed for the services.
Client #7 was admitted on August 3, 2023 and discharged on October 23, 2023. There was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the insurance was billed for the services.
This is a repeat citation from the September 24, 2020, June 2, 2021, June 23, 2022, and June 2, 2023 licensing inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
The Director of Quality Assurance will facilitate an in-service training dedicated to educating staff on the consent and release of member information June 20, 2024. The training will be documented in meeting minutes.
The Clinical Supervisor will review all charts on the day of admit to ensure a release of information has been completed for the client's funding source. If one is not found, the clinician will be informed and a release of information will be completed that same day.
The Quality Assurance Department will also review the charts semi-annually to ensure the releases are completed. All findings will be reported to the Program Director and Clinical Supervisor.
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709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. 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 procedures manual in four out of seven applicable records. The facility ' s policy states a psychosocial evaluation is completed within five days of admission.
Client #4 was admitted on August 25, 2023 and was discharged on January 5, 2024. A psychosocial evaluation was due no later than August 30, 2023; however, there was no documentation that a psychosocial evaluation was completed.
Client #5 was admitted on August 7, 2023 and was discharged on September 1, 2023. A psychosocial evaluation was due no later than August 12, 2023; however, there was no documentation that a psychosocial evaluation was completed.
Client #6 was admitted on December 21, 2023 and discharged on February 1, 2024. A psychosocial evaluation was due no later than December 26, 2023; however, there was no documentation that a psychosocial evaluation was completed.
Client #7 was admitted on August 3, 2023 and discharged on October 24, 2023. A psychosocial evaluation was due no later than August 8, 2023; however, there was no documentation that a psychosocial evaluation was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will review the policy and time frame of biopsychosocial completion with staff during an all staff meeting on 6/12/24.
The Clinical Supervisor will run the Clinical Forms Audit Report twice a week. This report will indicate if the biopsychosocial, as well as other documents, have been completed for each active client. If a biopsychosocial is missing, the Clinical Supervisor will advise the clinician to complete it by its due date. The clinical supervisor will follow up by checking to ensure the document was completed by either reviewing the chart or running the Clinical Forms Audit Report again. Missing or late documentation will be addressed in individual supervision between the clinical supervisor and clinician.
The Quality Assurance Manager will audit a sample of charts on a semiannual basis to ensure the biopsychosocial is being completed per regulations. Any issues noted will be reported to the Clinical Supervisor and Program Director to be addressed immediately.
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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 records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for obtaining an informed and voluntary consent from the client for the disclosure of information contained in the client record was submitted and approved by the Department for the September 24, 2020, June 2, 2021, June 23, 2022, and June 2, 2023, annual licensing inspections. Obtaining an informed and voluntary consent from the client for the disclosure of information contained in the client record was again found to be a deficiency in the May 21, 2024, licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will be ultimately responsible for the implementation and compliance of all plans of correction. The Program Director will collect data from past inspections to determine how to avoid repeated citations and the best procedures for implementing new POC. It will be the responsibility of the
Program Director and the Division Director to ensure that future violations are not incurred in this area and that POC is put in place. The Division Director will also ensure the POC is followed by meeting with the Program Director to audit past and present POC procedures.
The Quality Team will audit the program semiannually to make sure that the program remains in compliance. All data gathered from the monthly and quarterly audits will be recorded. These methods will focus on the proper protocol for completing client consents and releases, other relevant documentation, and POC.
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