INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 17, 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 two out of two applicable 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 #2 was hired on February 17, 2021 as a facility director and is still in that position at the time of the inspection. The annual work performance evaluation was not completed until February 12, 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 Division Director 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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709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
Based on a review of client records, the facility failed to provide documentation of medication being provided as prescribed by a physician in two out of seven client records.
Client #1 was admitted on December 18, 2023 and was still active at the time of the inspection. The client was prescribed one medication and the prescription stated that one tablet was to be taken in the morning. The medication administration records showed that the medication was not given on the morning of April 9, 2024. There was no additional documentation included indicating a reason why the medications were not given as prescribed.
Client #2 was admitted on January 4, 2024 and was still active at the time of the inspection. The client was prescribed two different medications and the prescriptions stated that one tablet was to be taken in the afternoon. The medication administration records showed that the one medication was not given in the afternoon of April 8, April 13, and April 16, 2024, and one medication was not given in the afternoon of April 13, 2024. There was no additional documentation included indicating a reason why the medications were not given as prescribed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
Program Director conducted a medication documentation training on 04/25/24, during our all-staff meeting to demonstrate proper Medication Administration Record (MAR) documentation, in accordance with 709.32. Training included how to document: omitted and refused medications and the comment section, completion on the reverse side of the form.
All staff will complete the Medication Monitoring and documentation training in our Relias web-based training system as well, no later than 5/31/24.
Program Director will review MARS Weekly and assist / retrain staff as needed in documented supervision.
The Quality Assurance department will complete at least semi-annual reviews the results of which will be shared with the Program Director immediately to be addressed as noted above.
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709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. 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 client records, the facility failed to develop an individual treatment and rehabilitation plan with the client within the policy timeframe in four out of seven applicable records reviewed. The facility ' s policy and procedure manual states that the comprehensive treatment plan will be developed with the client within thirty days of admission.
Client # 2 was admitted on January 4, 2024 and was still active at the time of the inspection. The individual treatment and rehabilitation plan completed on January 8, 2024 did not have documentation that it was developed with the client.
Client #3 was admitted on January 18, 2024 and was still active at the time of the inspection. The individual treatment and rehabilitation plan completed on January 24, 2024 did not have documentation that it was developed with the client.
Client #5 was admitted on September 26, 2023 and was discharged on November 20, 2023. The individual treatment and rehabilitation plan was due no later than October 26, 2023; however, there is no documentation that one was completed.
Client #6 was admitted on November 28, 2022 and was discharged on January 17, 2024. The individual treatment and rehabilitation plan was due no later than December 28, 2023; however, there is no documentation that one was completed.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
Program Director will completed all needed treatment plans for each existing client (Including clients at the time of the audit) and will ensure that going forward, treatment plans are kept current in each client record.
Program Director will ensure that new counselor (once hired) receives all required training in EHR on treatment plan development and timeframes.
Program Director will audit a sample of charts on at least a monthly basis, and any issues noted will be reviewed in a documented supervision and corrected within 48 hours.
The Quality Assurance department will complete at least semi-annual reviews the results of which will be shared with the Program Director immediately to be addressed as noted above.
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709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the facility ' s policy and procedure manual timeframe of every thirty days in five out of five applicable records reviewed.
Client #1 was admitted on December 18, 2023 and was still active at the time of the inspection. A treatment plan was completed on January 22, 2024, and the update was due no later than February 22, 2024; however, there was no documentation that one was completed.
Client #2 was admitted on January 4, 2024 and was still active at the time of the inspection. A treatment plan was completed on January 8, 2024, and the update was due no later than February 8, 2024; however, there was no documentation that one was completed.
Client #3 was admitted on January 18, 2024 and was still active at the time of the inspection. A treatment plan was completed on January 24, 2024, and the update was due no later than February 24, 2024; however, there is no documentation that one was completed.
Client #4 was admitted on November 28, 2023 and discharged on February 2, 2024. A treatment plan was completed on December 20, 2023, and the update was due no later than January 20, 2024; however, there was no documentation that one was completed.
Client #7 was admitted on May 17, 2023 and discharged on September 22, 2023. A treatment plan was completed on June 17, 2023, and the next update was due no later than July 17, 2023; however, there is no documentation that one was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
Program Director will completed all needed treatment plans for each existing client (Including clients at the time of the audit) and will ensure that going forward, treatment plans are kept current in each client record.
Program Director will ensure that new counselor (once hired) receives all required training in EHR on treatment plan development and timeframes.
Program Director will audit a sample of charts on at least a monthly basis, and any issues noted will be reviewed in a documented supervision and corrected within 48 hours.
The Quality Assurance department will complete at least semi-annual reviews the results of which will be shared with the Program Director immediately to be addressed as noted above.
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709.53(a)(8) LICENSURE Case Consultation Notes
709.53. 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 policy timeframe in five out of six applicable records reviewed. The facility's policy and procedure manual states case consultations are completed every ninety days unless the client ' s treatment is less than ninety days then one is completed prior to the end of the treatment episode.
Client #1 was admitted on December 18, 2023 and was still active at the time of the inspection. A case consultation was due no later than March 18, 2024; however, there is no documentation that one was completed.
Client #4 was admitted on November 28, 2023 and was discharged on February 2, 2024. 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 September 26, 2023 and was discharged on November 20, 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 November 28, 2023 and discharged on January 17, 2024. 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 May 17, 2023 and discharged on September 22, 2023. A case consultation was due no later than August 17, 2023; however, there is no documentation that one was completed.
This is a repeat citation from the May 5, 2022 and May 10, 2023 licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
The Program Director will ensure that clients are reviewed in a documented case consultation in accordance with Gaudenzia policy.
Program Director will ensure that new counselor (once hired) receives all required training in EHR on documentation completion and timeframes.
Program Director will audit a sample of charts on at least a monthly basis, and any issues noted will be reviewed in a documented supervision and corrected within 48 hours.
The Quality Assurance department will complete at least semi-annual reviews the results of which will be shared with the Program Director immediately to be addressed as noted above.
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709.53(a)(10) LICENSURE Discharge Summary
709.53. 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 four 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 November 28, 2023 and was discharged on February 2, 2024. A discharge summary was due no later than February 9, 2024; however, there is no documentation that one was completed.
Client #5 was admitted on September 26, 2023 and was discharged on November 20, 2023. A discharge summary was due no later than November 27, 2023; however, there is no documentation that one was completed.
Client #7 was admitted on May 17, 2023 and discharged on September 22, 2023. A discharge summary was due no later than September 29, 2023; however, it was not completed until October 2, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
Program Director will ensure that files reviewed during current audit cycle will have completed discharge summary's, in accordance with 709.53.(a)(10) This will be documented in the EHR utilizing the form specifically developed for this purpose.
Going forward, the Program Director will ensure that Discharge summary's are completed within the prescribed timeframe.
Program Director will ensure that new counselor (once hired) receives all required training in EHR on documentation completion and timeframes.
Program Director will audit a sample of charts on at least a monthly basis, and any issues noted will be reviewed in a documented supervision and corrected within 48 hours.
The Quality Assurance department will complete at least semi-annual reviews the results of which will be shared with the Program Director immediately to be addressed as noted above.
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709.53(a)(11) LICENSURE Follow-up information
709.53. 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 client records, the facility failed to provide a complete client record, which is to include follow-up information in three out of four discharged records reviewed. The facility ' s policy and procedures manual states that follow ups are to be completed within seven days of discharge.
Client #4 was admitted on November 28, 2023 and was discharged on February 2, 2024. A follow up was due no later than February 9, 2024; however, there is no documentation that one was completed.
Client #5 was admitted on September 26, 2023 and was discharged on November 20, 2023. A follow up was due no later than November 27, 2023; however, there is no documentation that one was completed.
Client #7 was admitted on May 17, 2023 and discharged on September 22, 2023. A follow up was due no later than September 29, 2023; however, it was not completed until October 2, 2023.
This is a repeat citation from the May 5, 2022 and May 10, 2023 licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
Program Director will ensure all client records are updated with documented follow-up calls, in accordance with regulation 709.53(a)11as well as Gaudenzia policy and within (7) days of discharge. This will be documented in the EHR utilizing the form specifically developed for this purpose.
Program Director will ensure that new counselor (once hired) receives all required training in EHR on documentation completion and timeframes.
Program Director will audit a sample of charts on at least a monthly basis, and any issues noted will be reviewed in a documented supervision and corrected within 48 hours.
The Quality Assurance department will complete at least semi-annual reviews the results of which will be shared with the Program Director immediately to be addressed as noted above.
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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 completing and documenting case consultations was submitted and approved by the Department for the May 5, 2022 and May 10, 2023 annual licensing inspections. Completing and documenting case consultations was again found to be a deficiency in the April 17, 2024, licensing inspection.
A plan of correction for completing and documenting follow up information was submitted and approved by the Department for the May 5, 2022 and May 10, 2023 annual licensing inspections. Completing and documenting follow up information was again found to be a deficiency in the April 17, 2024, licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director is ultimately responsible for the implementation of the corrective action items detailed above.
The Quality Assurance department will complete at least semi-annual reviews, which include review of any open corrective action plans, the results of which will be shared with the Program Director immediately to be addressed as noted above.
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