INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 13, 2023, 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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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to provide a written individual training plan for each employee, appropriate to that employee's skill level that documented it was developed annually with input from both the employee and the supervisor in two out of five personnel records reviewed.
Employee #2 was hired as a facility director on May 16, 2016 and was still in that position as of the date of the inspection. The individual training plan had no documentation that the plan was developed with input from both the employee and supervisor and the date completed.
Employee #3 was hired as a clinical supervisor on March 21, 2022 and was still in that position as of the date of the inspection. The individual training plan had no documentation that the plan was developed with input from both the employee and supervisor and the date completed.
Employee #4 was hired as a counselor on June 15, 2021 and was still in that position as of the date of the inspection. The individual training plan had no documentation that the plan was developed with input from both the employee and supervisor and the date completed.
Employee #5 was hired as a counselor on March 1, 2023 and was still in that position as of the date of the inspection. The individual training plan had no documentation that the plan was developed with input from both the employee and supervisor and the date completed.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Due to revisions made by the corporate training department as it relates to staff individualized training plans, supervisors neglected to obtain a separate staff signature verifying training goals were reviewed. Although new year training needs and goals are discussed in all performance reviews which receives staff signature a single training plan verification was not obtained. To correct this issue, all supervisors at Sunbury will review 2023 staff training needs and goals by July 15, 2023 and document this process in a supervisory session to be signed by the employee. Going forward this will be the same process in future years to ensure staff understand and participate in their own training goals. This will be part of the routine annual performance review requirement and will be reviewed for completion by facility Division Director. |
709.91(b)(6) LICENSURE Intake and admission
709.91. 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 psychosocial evaluation, within thirty days of admission, per facility policy, in three out of seven records.
Client #5 was admitted on March 21, 2023 and was still active at the time of the inspection. There was no documentation of a psychosocial evaluation at the time of the inspection.
Client # 6 was admitted on April 25, 2023 and still active at the time of the inspection. There was no documentation of a psychosocial evaluation at the time of the inspection.
Client # 7 was admitted on April 26, 2023 and was still active at the time of the inspection. There was no documentation of a psychosocial evaluation at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A clinical meeting will be held with staff by July 15, 2023 to address treatment management procedures specific to completion of the biopsychosocial upon initial session. All clinical staff will be directed to complete the biopsychosocial at intake. In order to address all requirements during the initial session, all intake sessions will be extended in time to ensure priority is given to completing all applicable requirements of the client history. All clients reviewed during this cite visit, as long as still active at the program, will have their biopsychosocial completed by July 30, 2023. The Division Director/supervisor will complete monthly audit reviews to ensure biopsychosocial histories are completed for each client. The CQI team as well as the Corporate Outpatient Director will in turn, complete their quarterly audits to address compliancy. The QA Managers as well as the Corporate Outpatient Director will complete quarterly chart audits to ensure compliance. Any issues noted will be documented in a Performance Improvement Plan to be addressed with clinicians and corrected within 48 hours. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. 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 document a comprehensive treatment plan within guidelines established by the facility's policy and procedures manual in three out of seven applicable records reviewed. The facility's policy and procedures manual states the comprehensive treatment plan must be completed within 30 days of admission.
Client #2 was admitted on March 7, 2023 and discharged on May 18, 2023. A comprehensive treatment plan was due no later than April 7, 2023; however, there was no documentation of it being completed at the time of the inspection.
Client #6 was admitted on April 25, 2023 and still active at the time of the inspection. A comprehensive treatment plan was due no later than May 25, 2023; however, it was completed on June 7, 2023.
Client #7 was admitted on April 26, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than May 26, 2023; however, there was no documentation that one was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A clinical meeting will be held with staff by July 15, 2023 to address treatment management procedures specific to completion of the client comprehensive treatment plan to be done with the client within 30 days of admission into treatment. All clinical staff will be directed to complete the comprehensive treatment plan with the client prior to the 30th day. Staff will be reminded that comprehensive treatment plans can always be done early when the client is present. Comprehensive treatment plans will be completed no later than July 30, 2023 for those clients identified who are still active in treatment. The Division Director/Supervisor will conduct monthly chart audits to ensure comprehensive treatment plans are being completed within the 30 day time frame. Clinical staff documentation will be monitored monthly in regular supervisory sessions. The QA Managers as well as the Corporate Outpatient Director will complete quarterly chart audits to ensure compliance. Any issues noted will be documented in a Performance Improvement Plan to be addressed with clinicians and corrected within 48 hours. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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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 aftercare information in four out of seven records reviewed. Per the facility ' s policy and procedure manual, the aftercare plan is to be started within 30 days of admission.
Client #2 was admitted on March 7, 2023 and discharged on May 18, 2023. There was no documentation of an aftercare plan in the record.
Client #5 was admitted on March 21, 2023 and still active at the time of the inspection. There was no documentation of an aftercare plan in the record.
Client #6 was admitted on April 25, 2023 and was still active at the time of the inspection. There was no documentation of an aftercare plan in the record.
Client # 7 was admitted on April 26, 2023 and was still active at the time of the inspection. There was no documentation of an aftercare plan in the record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A clinical meeting will be held with staff by July 15, 2023 to address treatment management procedures specific to continuing care/transition/discharge plan. Clinical staff will be reminded that the aftercare plan must be started within 30 days of admission into treatment and completed in its entirety upon discharge. The Division Director will review for compliance during the monthly internal CQI audit process. Additionally, quarterly audits will be completed quarterly by the QA Manager as well the Corporate Outpatient Director. All audit results are documented monthly via SharePoint and results are reviewed with staff during monthly supervisory sessions. |
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 the review of client records, the facility failed to document a discharge summary in one out of three applicable client records.
Client #2 was admitted on March 7, 2023 and discharged on May 18, 2023. There was no documentation that a discharge summary was completed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A clinical meeting will be held with staff by July 15, 2023 to address treatment management procedures specific to continuing care/transition/discharge plan. Clinical staff will be reminded that the discharge plan must be completed within 72 hours of a client's discharge from treatment. The Division Director/supervisor will review for compliance during the monthly internal CQI audit process. Additionally, quarterly audits will be completed by the Regional QA Manager as well the Corporate Outpatient Director. All audit results are documented monthly via SharePoint and results are reviewed with staff during monthly supervisory sessions. |