INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 16, 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 Together 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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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of staff schedules and CPR certifications provided by the facility, the facility failed to ensure that at least one person with current CPR certification was onsite during the project ' s hours of operations. The following shifts did not have staff with current CPR certification:
4/4/22 - 11:00 p.m. - 7:00 a.m.
4/10/22 - 11:00 p.m. - 7:00 a.m.
4/15/22 - 11:00 p.m. - 7:00 a.m.
4/16/22 - 11:00 p.m. - 7:00 a.m.
4/18/22 - 11:00 p.m. - 7:00 a.m.
4/19/22 - 11:00 p.m. - 7:00 a.m.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will ensure that at least one person with a current CPR certification is onsite during the program's hours of operations. The 11:00pm - 7:00am shift employees all received CPR certification on 07/07/2022. Additionally, all new staff hired through 07/07/22 also received CPR training.
All staff training records will be reviewed by the Program Director monthly. This review will be documented and maintained by the Program Director. Additionally, a centralized training grid has been developed by the Eastern Region Office and trainings will be monitored throughout the region monthly. The Deputy Regional Director and the Quality Assurance department will review all plan of correction items to ensure full implementation. The DRD will complete this monthly, and the QA Department will complete this quarterly. |
705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on a physical plant inspection on June 16, 2022, the facility failed to ensure that garbage was stored in covered containers that prevent the penetration of insects and rodents as a trash receptacle in the sallyport of the building was uncovered.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director and/or Recovery Support Supervisor will ensure that the lids on the dumpsters located on the side of the building (sallyport/dumpster area) always remain closed when trash is not being placed in the receptacle.
To assist with this, effective 07/15/22 there has been signage placed in the sallyport/dumpster area that reiterates that information. Additionally, this area is now included in a daily rounds checklist to ensure the dumpster lids are closed.
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705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection on June 16, 2022, the facility failed to provide either individual paper towels or a mechanical dryer in each bathroom as neither were in any client bathroom on the third and sixth floors.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director and/or Recovery Support Professional Supervisor (RSPS) will update the hourly rounds checklist sheet for the Recovery Support staff to include checking to ensure that there are individual paper towels in each bathroom. This new process will begin 07/21/22.
If deficiencies are noted in this area, during the rounds, it will be noted on the checklist sheet and corrected immediately. The checklist will be reviewed weekly by the RSPS and analyzed for trends and to ensure compliance. Any such trends
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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 procedures for the management of treatment/rehabilitation services for clients in two of two applicable records reviewed.
Client #2 was admitted on February 15, 2022 and discharged Against Medical Advise (AMA) on March 14, 2022. The facility failed to follow their policy related to AMA discharges of calling the Emergency Contact within twelve hours.
Client #4 was admitted on November 19, 2021 and discharged Against Medical Advise (AMA) on December 8, 2022. The facility failed to follow their policy related to AMA discharges of calling the Emergency Contact within twelve hours.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
The Program Director and/or Clinical Supervisor will continue to monitor confidential releases of information during monthly file audits to ensure that all Emergency Contacts are called for clients who leave treatment AMA, in accord with Gaudenzia's policy, and that there is a written record of such calls. Any discrepancies will be addressed during staff supervision.
The Program Director and/or Clinical Supervisor will facilitate a Clinical Documentation in-service training in which Emergency Contact protocols are reviewed, specifically regarding clients who discharge AMA. This training will be facilitated by 08/05/22.
The Program Director and/or Clinical Supervisor will complete at least bi-weekly audits of a sample of clinical charts using our Quantitative and Qualitative audit tools. Any incomplete or missing documentation will be brought to the attention of the staff member and corrected within 48 hours. This will be documented in a supervision note.
The Deputy Regional Director will complete at least monthly audits of a sample of clinical charts using our Quantitative and Qualitative audit tools. Any issues noted will be brought to the attention of the Program Director to be addressed with staff as noted above.
The Quality Assurance department complete at least quarterly audits of a sample of clinical charts using our Quantitative and Qualitative audit tools. Any issues noted will be brought to the attention of the Deputy Regional Director and Program Director to be addressed with staff as noted above.
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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
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.
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.
Gaudenzia will obtain a completed financial audit from the independent certified public accounting firm on or before September 30th of 2022.
The Chief Financial Officer will oversee this process.
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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 a review of seven client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in two records reviewed.
Client #1 was admitted on April 5, 2022 and was discharged on April 22, 2022. The record did not contain a client signed consent to release information form to the funding source, however, the record contained evidence that billing occurred during that time period. Additionally, the record contained documentation of identifying information and lab work released to a diagnostic laboratory on April 5, 2022, to whom there was no client signed consent to release information form. A call to the P.O. was documented on April 22, 2022, to whom there was no client signed consent to release information form.
Client #6 was admitted on May 16, 2022 and was discharged on June 14, 2022. The record contained documentation of identifying information and lab work released to a diagnostic laboratory on May 19, 2022, to whom there was no client signed consent to release information form.
This is a repeat citation from the June 24, 2021 and October 6, 2020 annual 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 and/or Clinical Supervisor will review all other active charts and ensure that there is an informed and voluntary consent form for them as needed, to include releases for diagnostic laboratories.
The Program Director and/or Clinical Supervisor will continue to monitor confidential releases of information during monthly file audits and address any discrepancies during staff supervision. The CQI department will also monitor confidentiality and releases of information during quarterly CQI file audits and will report findings to the Program Director.
As most of the clinical staff are new to the program, the Program Director and/or Clinical Supervisor will facilitate a Voluntary Consent/Releases of Information in-service with all clinical staff by 08/05/22.
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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 seven client records, the facility failed to document that the client was notified, in writing, of the facility's decision to involuntarily terminate the client's treatment at the project in one of one applicable record reviewed.
Client #1 was admitted on April 5, 2022 and was therapeutically discharged on April 22, 2022. There was no documentation that the client was notified, in writing, of the facility's decision to involuntarily terminate.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director and/or Clinical Supervisor is involved in all decisions involving an involuntary termination of a client's treatment. During the discharge process, the Program Director and/or Clinical Supervisor will ensure that the client receives a written notification of that decision prior to his discharge from the program. A copy of this notification will be maintained as apart of the client's treatment file.
The Program Director and/or Clinical Supervisor will facilitate a Clinical Documentation in-service training in which the following is reviewed: (1) the process of the client receiving this written notification, (2) the importance of this written notification and the (3) the process of including this notification in the client's treatment file. This training will be facilitated by 08/05/22.
The Program Director and/or Clinical Supervisor will complete at least bi-weekly audits of a sample of clinical charts using our Quantitative and Qualitative audit tools. Any incomplete or missing documentation will be brought to the attention of the staff member and corrected within 48 hours. This will be documented in a supervision note.
The Deputy Regional Director will complete at least monthly audits of a sample of clinical charts using our Quantitative and Qualitative audit tools. Any issues noted will be brought to the attention of the Program Director to be addressed with staff as noted above.
The Quality Assurance department complete at least quarterly audits of a sample of clinical charts using our Quantitative and Qualitative audit tools. Any issues noted will be brought to the attention of the Deputy Regional Director and Program Director to be addressed with staff as noted above.
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709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on the review of the unusual incident logbook, the project failed to file a written unusual incident report with the Department within three business days following an unusual incident involving the physical or sexual assault by staff or a client.
There was documentation of a patient assault on April 1, 2022 and an assault on staff on January 27, 2022; however, there was no documentation that written unusual incident reports were ever filed with the Department.
This is a repeat citation from the June 24, 2021 annual licensing inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Program Director has reviewed and forwarded all unusual incident reports noted as of 7/20/22.
The Program Director will review the incident log on a weekly basis to ensure that all reports are sent to the Department within 3 days.
Our upgraded Incident Reporting system includes an email alert to the Program Director for any incident which may require notification to DDAP.
In addition, on a quarterly basis the CQI Department will review the incident log to ensure compliance and report findings to the Program Director.
Any discrepancies and/or deficiencies noted will be corrected and the appropriate reports will be sent. It will also be addressed with the appropriate staff in supervision.
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709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on the review of the unusual incident logbook, the project failed to file a written unusual incident report with the Department within three business days following an unusual incident involving the presence of police, fire, or ambulance personnel.
There was documentation of the presence of ambulance personnel on May 4, 2022, March 6, 2022, and February 1, 2022, as well as police personnel on January 12, 2022; however, there was no documentation that written unusual incident reports were ever filed with the Department.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Program Director has reviewed and forwarded all unusual incident reports noted as of 7/20/22, of any event at the facility requiring the presence of police, fire or ambulance personnel.
The Program Director will review the incident log on a weekly basis to ensure that all reports are sent to the Department within 3 days.
Our upgraded Incident Reporting system includes an email alert to the Program Director for any incident which may require notification to DDAP.
In addition, on a quarterly basis the CQI Department will review the incident log to ensure compliance and report findings to the Program Director.
Any discrepancies and/or deficiencies noted will be corrected and the appropriate reports will be sent. It will also be addressed with the appropriate staff in supervision.
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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 ensure an individual treatment and rehabilitation plan was completed within 15 days of the completion of the preliminary treatment plan, per the procedures of the facility, in three of five applicable records reviewed.
Client #2 was admitted on February 15, 2022 and was discharged on March 14, 2022. The preliminary treatment plan was completed on February 17, 2022, and the individual treatment and rehabilitation plan was due to be completed by March 1, 2022; however, it was not completed prior to the client ' s discharge.
Client #6 was admitted on May 16, 2022 and was discharged on June 14, 2022. The preliminary treatment plan was completed on May 19, 2022, and the individual treatment and rehabilitation plan was due to be completed by June 2, 2022; however, it was not completed prior to the client ' s discharge.
Client #7 was admitted on May 13, 2022 and was active at the time of the inspection. The preliminary treatment plan was completed on May 18, 2022, and the individual treatment and rehabilitation plan was due to be completed by June 1, 2022; however, it was not completed until June 12, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As most of the clinical staff are new to the program, the Program Director and/or Clinical Supervisor will facilitate an Individual Treatment and Rehabilitation plan in-service with all clinical staff by 08/05/22.
The Program Director and/or Clinical Supervisor will complete at least bi-weekly audits of a sample of clinical charts using our Quantitative and Qualitative audit tools. Any incomplete or missing documentation will be brought to the attention of the staff member and corrected within 48 hours. This will be documented in a supervision note.
The Deputy Regional Director will complete at least monthly audits of a sample of clinical charts using our Quantitative and Qualitative audit tools. Any issues noted will be brought to the attention of the Program Director to be addressed with staff as noted above.
The Quality Assurance department complete at least quarterly audits of a sample of clinical charts using our Quantitative and Qualitative audit tools. Any issues noted will be brought to the attention of the Deputy Regional Director and Program Director to be addressed with staff as noted above.
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709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plans in four of five applicable records reviewed.
Client #2 was admitted on February 15, 2022 and was discharged on March 14, 2022. The treatment plan completed on February 17, 2022, indicated that the client was to receive one individual session per week; however, the record contained no documentation of individual sessions after February 28, 2022.
Client #3 was admitted on March 9, 2022 and was discharged on May 11, 2022. The treatment plan completed on April 6, 2022, indicated that the client was to receive one individual session per week; however, the record contained no documentation of individual sessions after March 28, 2022.
Client #4 was admitted on November 19, 2021 and was discharged on December 8, 2021. The treatment plan completed on November 23, 2021, indicated that the client was to receive one individual session per week; however, the record contained no documentation of individual sessions after November 23, 2021.
Client #7 was admitted on May 13, 2022 and was active at the time of the inspection. The treatment plan completed on May 18, 2022, indicated that the client was to receive one individual session per week; however, the record contained no documentation of sessions between May 19, 2022 and June 19, 2022.
This is a repeat citation from the June 24, 2021 and October 6, 2020 annual licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counselors are now to submit to the Program Director weekly confirmation of sessions having occurred for the week according to the Treatment Plan for each client.
As most of the clinical staff are new to the program, the Program Director and/or Clinical Supervisor will facilitate an Individual Treatment and Rehabilitation plan in-service with all clinical staff by 08/05/22.
The Program Director and/or Clinical Supervisor will complete at least bi-weekly audits of a sample of clinical charts using our Quantitative and Qualitative audit tools. Any incomplete or missing documentation will be brought to the attention of the staff member and corrected within 48 hours. This will be documented in a supervision note.
The Deputy Regional Director will complete at least monthly audits of a sample of clinical charts using our Quantitative and Qualitative audit tools. Any issues noted will be brought to the attention of the Program Director to be addressed with staff as noted above.
The Quality Assurance department complete at least quarterly audits of a sample of clinical charts using our Quantitative and Qualitative audit tools. Any issues noted will be brought to the attention of the Deputy Regional Director and Program Director to be addressed with staff 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 a review of client records, the facility failed to ensure a complete client record on an individual which includes information relative to the client's involvement with the project including case consultation notes in four of four applicable records reviewed.
Client #1 was admitted on April 5, 2022 and was discharged on April 22, 2022. The client record did not contain documentation of case consultation notes.
Client #2 was admitted on February 15, 2022 and was discharged on March 14, 2022. The client record did not contain documentation of case consultation notes.
Client #3 was admitted on March 9, 2022 and was discharged on May 11, 2022. The client record did not contain documentation of case consultation notes.
Client #4 was admitted on November 19, 2021 and was discharged on December 8, 2021. The client record did not contain documentation of case consultation notes.
This is a repeat citation from the June 24, 2021 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clients will have a Case Consultation completed at the 15-day mark, and every 90 days thereafter. The Clinical Supervisor, or their designee will identify case consultations that are due and will send a reminder email/report each week noting which clients are due for case consultations.
The Program Director and/or Clinical Supervisor will facilitate a Clinical Documentation in-service training in which Case Consultations are reviewed. This training will be facilitated by 08/05/22.
The Program Director and/or Clinical Supervisor will complete at least bi-weekly audits of a sample of clinical charts using our Quantitative and Qualitative audit tools. Any incomplete or missing documentation will be brought to the attention of the staff member and corrected within 48 hours. This will be documented in a supervision note.
The Deputy Regional Director will complete at least monthly audits of a sample of clinical charts using our Quantitative and Qualitative audit tools. Any issues noted will be brought to the attention of the Program Director to be addressed with staff 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 ensure a complete client record on an individual which includes information relative to the client's involvement with the project including a discharge summary completed within seven days of discharge in two of five applicable records reviewed.
Client #2 was admitted on February 15, 2022 and was discharged on March 14, 2022. The client record did not contain documentation of a discharge summary.
Client #4 was admitted on November 19, 2021 and was discharged on December 8, 2021. The client record did not contain documentation of a discharge summary completed within seven days of the client ' s discharge, the timeframe established in their policy.
This is a repeat citation from the June 24, 2021 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Discharge Summaries will be completed for these charts no later than 7/28/22.
The Program Director and/or Clinical Supervisor will conduct weekly audits to monitor that the discharge summaries are completed within seven (7) days of the client's discharge. The Clinical Supervisor, or their designee will identify planned/pending discharges and identify unplanned discharges (AMA's) each week and will send a reminder email/report each week noting which clients are due for or have discharged to ensure that the discharges are completed within 7 days of the client's discharge. Any discrepancies will be addressed during staff supervision.
The Program Director and/or Clinical Supervisor will complete at least bi-weekly audits of a sample of clinical charts using our Quantitative and
Qualitative audit tools. Any incomplete or missing documentation will be brought to the attention of the staff member and corrected within 48 hours. This will be documented in a supervision note.
The Deputy Regional Director will complete at least monthly audits of a sample of clinical charts using our Quantitative and Qualitative audit tools. Any issues noted will be brought to the attention of the Program Director to be addressed with staff as noted above.
The Quality Assurance department complete at least quarterly audits of a sample of clinical charts using our Quantitative and Qualitative audit tools. Any issues noted will be brought to the attention of the Deputy Regional Director and Program Director to be addressed with staff as noted above.
The Program Director and/or Clinical Supervisor will facilitate a Discharge Summary in-service training, which will review the need to have this document completed and submitted in the client's file withing seven (7) days of the client's discharge. This training will be facilitated by 08/05/22.
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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 ensure a complete client record included information relative to the client's involvement with the project to include follow-up information in two of three applicable records reviewed.
Client #1 was admitted on April 5, 2022 and was discharged on April 22, 2022. The client record did not contain documentation of follow-up information.
Client #3 was admitted on March 9, 2022 and was discharged on May 11, 2022. The client record did not contain documentation of follow-up information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director and/or Clinical Supervisor will review all discharges from 07/01/22 and ensure that there is a written record documenting follow-up with clients in accord with Gaudenzia's policy.
The Clinical Supervisor and/or the Intake/Aftercare Counselor and the Utilization Review Specialist will identify follow-ups that are due and will ensure that appropriate follow-ups are conducted.
The Program Director and/or Clinical Supervisor will continue to monitor follow-up with clients during monthly file audits and address any discrepancies during staff supervision. The CQI department will also monitor client follow-up during quarterly CQI file audits and will report findings to the Program Director.
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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 client signed consent to release information forms prior to disclosures of information was submitted and approved by the Department for the June 24, 2021 and October 6, 2020 annual licensing inspections. Obtaining client signed consent to release information forms prior to disclosing information was again found to be a deficiency in the June 16, 2022 licensing inspection.
A plan of correction for providing counseling services according to the treatment plan was submitted and approved by the Department for the June 24, 2021 and October 6, 2020 annual licensing inspections. Providing counseling services according to the treatment plan was again found to be a deficiency in the June 16, 2022 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Deputy Regional Director and Program Director are responsible for ensuring that the plan of correction is implemented.
In addition to the monthly chart audits conducted by the Program Director, Clinical Supervisor and the quarterly chart audits conducted by the CQI department, the Deputy Regional Director will complete monthly Plan of Correction audits that specifically address the deficiencies in the plans of correction. The purpose of this audit is to ensure implementation of and compliance with the plan of correction.
These findings will be reviewed with the Program Director. Any discrepancies will be addressed with the appropriate clinical staff and appropriate action taken to ensure compliance. |