INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 21, 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 four 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, 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.
Employee #4 was hired as a counselor 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 #5 was hired as a counselor on March 26, 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.
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 upon completion, a single training plan verification was not obtained. To correct this issue, all supervisors at Middleburg will review 2023 staff training needs and goals by July 30th, 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 the facility Division Director. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on the review of client records, the facility failed to document a medical history, during the first appointment as per policy, in two out of five applicable records.
Client #1 was admitted on March 28, 2023 and was still active at the time of the inspection. A medical history was due to be completed on that date; however, it wasn ' t completed until April 12, 2023.
Client # 2 was admitted on April 13, 2023 and was still active at the time of the inspection. A medical history was due to be completed on that date; however, it wasn ' t completed until June 16, 2023.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
A clinical meeting will be held with staff by August 8, 2023 to address treatment management procedures specific to obtaining client medical history via completion on the biopsychosocial upon initial session. All clinical staff will be directed to complete the medical portion of 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. The Division Director will review biopsychosocial documents for completion when submitted for approval as well as during the CQI process monthly. 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. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on the review of client records, the facility failed to document a drug and alcohol history, during the first appointment as per policy, in two out of five applicable records.
Client #1 was admitted on March 28, 2023 and was still active at the time of the inspection. A drug and alcohol history was due to be completed on that date; however, it wasn ' t completed until April 12, 2023.
Client # 2 was admitted on April 13, 2023 and was still active at the time of the inspection. A drug and alcohol history was due to be completed on that date; however, it wasn ' t completed until June 16, 2023.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
A clinical meeting will be held with staff by August 8, 2023 to address treatment management procedures specific to obtaining client drug & alcohol history via completion on the biopsychosocial upon initial session. All clinical staff will be directed to complete the drug & alcohol portion of 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. The Division Director will review biopsychosocial documents for completion when submitted for approval as well as during the CQI process monthly. 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. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on the review of client records, the facility failed to document a personal history, during the first appointment as per policy, in two out of five applicable records.
Client #1 was admitted on March 28, 2023 and was still active at the time of the inspection. A personal history was due to be completed on that date; however, it wasn ' t completed until April 12, 2023.
Client # 2 was admitted on April 13, 2023 and was still active at the time of the inspection. A personal history was due to be completed on that date; however, it wasn ' t completed until June 16, 2023.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
A clinical meeting will be held with staff by August 8, 2023 to address treatment management procedures specific to obtaining client personal history via completion of the biopsychosocial upon initial session. All clinical staff will be directed to complete the personal history portion of 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. The Division Director will review biopsychosocial documents for completion when submitted for approval as well as during the CQI process monthly. 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. |
709.92(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 six applicable records reviewed. The facility's policy and procedures manual states the comprehensive treatment plan must be completed within 30 days of admission.
Client #1 was admitted on March 28, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than April 28, 2023; however, it wasn ' t completed until May 2, 2023.
Client #2 was admitted on April 18, 2023 and still active at the time of the inspection. A comprehensive treatment plan was due no later than May 18, 2023; however, it wasn ' t completed until May 19, 2023.
Client #3 was admitted on January 5, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than February 5, 2023; however, it wasn ' t completed until March 23, 2023.
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 August 8, 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. 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. |
709.92(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, the facility failed to document treatment plan updates within the regulatory timeframe in four out of seven records reviewed.
Client #4 was admitted on February 3, 2023 and was still active at the time of the inspection. A treatment plan was completed on March 3, 2023, and the next update was due no later than May 3, 2023; however, there was no documentation that one was completed.
Client #5 was admitted on February 1, 2023 and discharged on May 3, 2023. A treatment plan was completed on March 1, 2023, and the next update was due no later than May 1, 2023; however, there was no documentation that one was completed.
Client #6 was admitted on May 4, 2022 and discharged on March 13, 2023. A treatment plan was completed on August 17, 2022, and the next update was due no later than October 17, 2022; however, it wasn ' t completed until November 9, 2022. The next update was due no later than January 9, 2023; however, it wasn ' t completed until January 18, 2023.
Client #7 was admitted on May 23, 2022 and was discharged on April 24, 2023. A treatment plan was completed on June 23, 2022, and the next update was due no later than August 23, 2022; however, it wasn ' t completed until August 25, 2022. The next update was due no later than October 25, 2022; however, it wasn ' t completed until December 13, 2022. The next update was due no later than January 13, 2023; however, it wasn ' t completed until March 14, 2023.
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 August 8, 2023 to address treatment management procedures specific to completion of the treatment plan updates. All clinical staff will be directed to complete the updates within 30 days of the last treatment plan if intensive outpatient status. For outpatient level of care status, staff will be reminded that updates are due within 60 days of the last treatment plan and can always be done early or prior to the due date. Should client #4 still be active, staff will be directed to complete a treatment plan update by August 15, 2023. 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)(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 client records, the facility failed to provide a complete client record, which is to include case consultations, quarterly per facility policy, in five out of five applicable records reviewed.
Client #3 was admitted on January 5, 2023 and was still active at the time of the inspection. A case consultation was due no later than April 5, 2023; however, it wasn ' t completed until June 19, 2023.
Client #4 was admitted on February 3, 2023 and still active at the time of the inspection. A case consultation was due no later than May 3, 2023; however, there was no documentation that one was completed.
Client #5 was admitted on February 1, 2023 and discharged on May 3, 2023. A case consultation was due no later May 1, 2023; however, there was no documentation that one was completed.
Client #6 was admitted on May 4, 2022 and discharged on March 13, 2023. A case consultation was due no later than August 4, 2022; however, there was no documentation that one was completed.
Client #7 was admitted on May 23, 2022 and discharged on April 24, 2023. A case consultation was due no later than August 23, 2022; 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 August 8, 2023 to address treatment management procedures specific to case consults. Clinical staff will be reminded that case consults are due every 90 days at a minimum unless the client is discharged prior to the 90 days at which time a consult is due. Should client #4 still be active, a case consult will be completed by August 15, 2023. 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. |
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 three 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 #3 was admitted on January 5, 2023 and was still active at the time of the inspection. The aftercare plan was due to be started no later than, February 5, 2023; however, it wasn ' t started until May 11, 2023.
Client #5 was admitted on February 1, 2023 and discharged on May 3, 2023. The aftercare plan was due to be started no later than March 1, 2023; however, it wasn ' t started until April 3, 2023.
Client # 7 was admitted on May 23, 2022 and discharged on April 24, 2023. The aftercare plan was due to be started no later June 23, 2022; however, there was no documentation that one was started.
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 August 8, 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 it's entirety upon discharge. Should client # 7 still be active, staff will be directed to begin the plan no later than August 15, 2023. Should client #7 be discharged, the supervisor will follow up to ensure the document is fully completed by August 15, 2023. 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 #7 was admitted on May 23, 2022 and discharged on April 24, 2023. There is 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 August 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. |
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 client records, the facility failed to provide a complete client record, which is to include follow up information, within 30 days of discharge per facility policy, in two out of three applicable records reviewed.
Client #5 was admitted on February 1, 2023 and discharged on May 3, 2023. There was no documentation that follow up information was completed.
Client #6 was admitted on May 4, 2022 and discharged on March 13, 2023. The follow up information was due no later than April 13, 2023; however, was not completed until April 28, 2023.
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 August 8, 2023 to address treatment management procedures specific to client follow up after discharge. Staff will be reminded that for those clients referred to another program or service, upon receiving written client consent, a follow up phone call will occur within 7 days of discharge/referral. For all other types of discharges (ASA, completion, non ? compliance) a follow up phone call will be done within 30 days of client discharge. All follow up will be completed by the onsite Certified Recovery Specialist or other assigned staff. Client #5 will receive a follow up phone call by August 15, 2023. The Division Director/supervisor will review for compliance during the monthly internal CQI audit process using a standard tool which lists follow up as an item. 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. Follow up reminders have been added in the electronic health record "My To Do List" for staff assigned.
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