INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 31, 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 West Shore 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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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of nine fire drill records, the facility failed to include the amount of time it took for the evacuation and the exit routes used to evacuate the building on the fire drill dated March 10, 2022.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Division Director reviewed with Administrative Assistant on 4/22/2022 during supervision the required documentation for a fire drill to include but not limited to; exit route used, evacuation time.
During this same supervision session, Division Director and Administrative Assistant corrected the fire drill log for March 10th, 2022 by adding the exit used and evacuation time.
Division Director will continue to monitor safety drills (including fire drills) with Administrative Assistant on a monthly basis, prior to each safety meeting committee meeting.
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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of seven client records, the facility failed to follow their written plan for the coordination of client treatment and rehabilitation services which includes the written procedures for the management of treatment/rehabilitation services for one client reviewed.
The facility ' s written plan for completing client orientation is for it to be completed at intake. Client #5 was admitted on May 10, 2021 and was discharged on June 20, 2021. The client orientation was not completed until June 9, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
December 2021, Gaudenzia released a new bundle of forms to be completed at the time of Intake. This form includes the Orientation Plan. The clinical staff completed training on this addition to the EHR with their Division Director in mid-December, following the form release.
Since this form release, the program has completed the Orientation Plan 100% of the time as evidenced by monthly CQI chart audits that are done by the CQI manager and the Division Director.
Chart compliance will continue to be completed monthly by the Division Director and quarterly by the CQI manager.
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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.
Completion date: 9/30/2022 |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the project failed to notify one applicable client, in writing, of a decision to involuntarily terminate the client's treatment at the project.
Client #7 was admitted on February 17, 2022 and was discharged March 4, 2022. The client record did not have documentation in writing of the project ' s decision to involuntary discharge the client ' s treatment at the project.
These findings were discussed with project staff during the licensing process.
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Plan of Correction
A clinical document training has been scheduled for May 2nd, 2022. During this in-service, Division Director will review the policy that when a decision has been made to involuntarily terminate an individual's treatment that the client will receive the notice in writing and that it will include the reason.
The Division Director will also review the form, Termination Notice that is in the agency's Electronic Health Record. The review will include how to complete and how to print it off so that it can be mailed.
Ongoing chart compliance will continue to be completed monthly by the Division Director and quarterly by the CQI manager. For the first 3 months following the training (ending in July), Division Director will document compliance for discharged clients whose treatment was terminated.
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709.91(b)(2)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(ii) Hours of operation.
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Observations
Based on a review of client records, the facility failed to include documentation of the client ' s orientation to the project that included a familiarization to the hours of operation in seven out of seven records reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In December 2021, Gaudenzia released a new bundle of forms to be completed at the time of Intake. This form includes the Orientation Plan. The clinical staff completed training on this addition to the EHR with their Division Director in mid-December, following the form release.
The Orientation Plan review form has added language that indicates at the time of signature, the client will receive a paper copy of the program's handbook. The handbook indicates the hours of operation for the specific program.
Chart compliance will continue to be completed monthly by the Division Director and quarterly by the CQI manager to ensure the form is being completed.
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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 on March 28, 2022, 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 June 14, 2021 and was discharged on November 16, 2021. A treatment plan update was completed on July 8, 2021, and the next two updates were due by September 8, 2021 and November 8, 2021; however, there were no additional treatment plans documented in the client record at the time of inspection.
Client #2 was admitted on July 20, 2021 and was current at the time of the inspection. There were no treatment plans documented in the client record at the time of the inspection.
Client #4 was admitted on January 21, 2022 and was current at the time of the inspection. An initial treatment plan was completed on January 21, 2022, and the next update was due by March 21, 2022; however, there was not one documented at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from a licensing inspection that took place on June 7, 2021.
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Plan of Correction
A clinical document training has been scheduled for May 2nd, 2022. During this in-service, Division Director will review the policy that treatment plans need to be reviewed and updated at least every 60 days.
At the time of the in-service, the Division Director will provide a Treatment Plan Analysis report for each clinician. This report will provide a list of their caseload and dates of when the next treatment plan update will be due.
Ongoing this report will be run each Friday, beginning May 6th, 2022 and given to the clinicians during the scheduled weekly Clinical Meeting so that they can plan ahead for the next week of scheduled sessions.
Chart compliance audits will continue to be completed monthly by the Division Director and the quarterly by the CQI manager. Following an audit, counselors are given 2 weeks to make appropriate corrections/updates. The Division Director follows up every 14 days by reviewing the chart a second time.
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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 seven client records, the project failed to include case consultation notes in one of three applicable records reviewed.
Client #5 was admitted on May 10, 2021 and discharged on June 20, 2021. Client #5 did not have a case consultation documented in their record at the time of the inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
A clinical document training has been scheduled for May 2nd, 2022. During this in-service, Division Director will review the policy that a case consultation is required in every chart.
Clinical Meeting is scheduled weekly at the program and for the first 3 months following the training (ending July) the Division Director will come to the clinical meeting with a list of individuals who need a case consultation (in treatment greater than 90 days). The cases will be reviewed and compliance of complete documentation will be followed up at the next weekly meeting by the Division Director.
For follow up, the Division Director will monitor the completeness of the Case Consultation as she is required to sign each one electronically.
For individuals who are in treatment less than 90 days and are being reviewed at the weekly Clinical Meeting, the Division Director will monitor the completion of the Case Consultation in the same manner and review the following week.
Any outstanding consultations at that time will have a requirement of being completed by End of Business the day of the meeting.
Chart compliance audits will continue to be completed monthly by the Division Director and quarterly by the CQI manager. Following an audit, counselors are given 2 weeks to make appropriate corrections/updates. The Division Director follows up every 14 days by reviewing the chart a second time.
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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 seven client records, the project failed to have a complete client record on two applicable clients that included information relative to the client's involvement with the project, including a discharge summary.
Client #6 was admitted on January 26, 2022 and was discharged on February 15, 2022. Client #6 did not have documentation of discharge summary in the client record.
Client # 7 was admitted on February 17, 2022 and was discharged on March 4, 2022. Client #7 had a blank discharge summary in the client record.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Division Director has scheduled individual supervision with the clinician who was responsible for the two charts that were reviewed during the inspection on March 31st, 2022 that were required to have a Discharge Summary completed.
The supervision will include review of the two records; one of which was finalized, but was blank. The Division Director will go through each element of the Discharge Summary and discuss not only what needs to be included, but how it can documented depending on the discharge type.
The Division Director will ask that completion of discharge summaries for both Client #7 and #6 be completed by May 6th, 2022.
The Division Director will verify completion and compliance of the document is sent to her for required signature through the EHR.
Chart compliance audits will continue to be completed monthly by the Division Director and quarterly by the CQI manager. 10% of charts audited will be discharged clients. Following an audit, counselors are given 2 weeks to make appropriate corrections/updates. The Division Director follows up every 14 days by reviewing the chart a second time.
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709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of seven client records, the project failed to have a complete client record on one of three applicable clients that included information relative to the client's involvement with the project, including follow-up information.
Client #6 was admitted on January 26, 2022 and was discharged on February 15, 2022. Client #6 did not have documentation of follow-up information in the client record.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
A clinical document training has been scheduled for May 2nd, 2022. During this in-service, Division Director will review the policy of completing Follow-up Information for discharged clients. The review will include the form that is required to be completed in our Electronic Health Record as well as the timeframe of when Follow Up documentation is due.
Chart compliance audits will continue to be completed monthly by the Division Director and quarterly by the CQI manager. 10% of charts audited will be discharged clients. Following an audit, counselors are given 2 weeks to make appropriate corrections/updates. The Division Director follows up every 14 days by reviewing the chart a second time.
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