INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 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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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to document instruction in the use of fire extinguishers upon staff employment in one of six applicable records.
Staff #6 was hired on February 13, 2023. There was no documentation of staff #6 being trained in the use of fire extinguishers at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff that have not received training will take Fire Safety on Relias by 10/30/2023. All staff will take and complete Fire Safety through Relias on their first day of employment with Gaudenzia. Process will be monitored by the Program Director/Clinical Director Relias and reviewed with Division Director to ensure compliance.
Any issues noted will be brought to the attention of program management to be addressed immediately. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel are trained to perform assigned tasks during emergencies in one of six applicable records.
Staff #6 was hired on February 13, 2023. There was no documentation of staff #6 being trained to perform assigned tasks during emergencies during the onsite inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff that have not received training will take Fire Safety and CARF on Relias by 10/30/2023. All staff will take and complete Fire Safety and CARF training through Relias on their first day of employment with Gaudenzia. Process will be monitored by the Program Director/Clinical Director Relias and reviewed with Division Director to ensure compliance.
Any issues noted will be brought to the attention of program management to be addressed immediately. |
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 review and update treatment and rehabilitation plans within 60 days in three of seven applicable client records.
Client #3 was admitted on June 7, 2023 and discharged on August 31, 2023. A treatment plan was completed on June 7, 2023 and an update was due by August 7, 2023 but not completed until August 17, 2023.
Client #4 was admitted on April 5, 2023 and discharged on August 8, 2023. A treatment plan was completed on May 11, 2023 and an update was due by July 10, 2023 but not completed until August 8, 2023.
Client #5 was admitted on May 26, 2023 and still a client at the time of inspection. A treatment plan was completed on May 26, 2023 and an update was due by July 25, 2023 but not completed until August 2, 2023.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from September 12, 2022.
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Plan of Correction
Clinical Supervisor will review expectations of clinical documentation and timelines in Group/Individual supervision by 11/20/2023.
The clinical forms audit and treatment plan analysis report in the agency EHR will be reviewed in group and individual supervision to alert clinicians of upcoming treatment plans that need completed.
Progress will be monitored by monthly chart audits and reviewed with Clinicians monthly. Quarterly chart audits will also be conducted by CQI Manager to assist in maintaining compliance with timely submission of required documentation.
Any issues noted will be brought to the attention of program management to be addressed immediately. |
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 complete case consultations in four of four applicable records reviewed. Per agency policy and procedures, case consultations are to be completed within 90 days of admission.
Client #4 was admitted on April 5, 2023 and discharged on August 8, 2023. There was no documentation of a case consultation being completed for this client.
Client #5 was admitted on May 26, 2023 and still a client at the time of inspection. There was no documentation of a case consultation being completed for this client.
Client #6 was admitted on April 21, 2023 and still a current client at the time of inspection. There was no documentation of a case consultation being completed for this client.
Client #7 was admitted on January 27, 2023 and still a client at the time of inspection. There was no documentation of a case consultation being completed for this client.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from September 12, 2022.
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Plan of Correction
Clinical Supervisor will Review case consultation procedures and timelines for documentation in group and individual supervision by 11/20/2023.
Census will be reviewed by Clinical Supervisor in weekly staff meeting to alert clinicians of to case consultations that are coming due. Clinical Supervisor will follow up weekly to ensure that they are completed.
Progress will be monitored in monthly chart audits and reviewed with clinicians monthly. Quarterly chart audits will be conducted by CQI Manager to assist in maintaining compliance with timely submission of required documentation.
Any issues noted will be brought to the attention of program management to be addressed immediately. |