INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 18-19, 2019 of Gaudenzia Coal Township by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Gaudenzia Coal Township 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(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of the policy and procedure manual, the facility failed to follow their policy in regard to completion of the assessment of staff training needs. The Plan for Assessing Staff Training Needs policy stated, "The training plan shall be ready for implementation effective Jan. 31st of each year." The overall training plan for the project was not completed until May 16, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The relevant Gaudenzia Policy has been revised to state that, "Program-level training needs assessments are due to the Training department by the end of January of each year. Upon receipt of the program-level annual assessments of staff training needs, the Director of Training and Education, in collaboration with the Project Director, will review the assessments in detail and develop a plan to address the training needs of the agency. The annual agency-wide training plan shall be ready for implementation no later than April 30th of each year." The Gaudenzia Director of Training and Education will ensure that this is completed within the designated timeframe each year.
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705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel files, employee #1 was not trained in fire extinguisher use upon hire. Employee #1 was hired on March 19, 2019 and was still employed at the time of the inspection. There was no documentation that he employee received the training as of the date of this inspection July 18-19th 2019.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director completed this training on 6/7/19 and documentation of this has been placed in his file. All relevant staff within the HR and Training departments will review the DDAP 705.10 (c) (4) - 705.28 (c) (4) regulations by 7/31/19, and as the head of the Training department, the Director of Training and Education will be ultimately responsible for ensuring that all staff (to include administrative staff) receive required fire extinguisher training upon hire. Training department staff will review all staff files during the orientation process to ensure that this training is completed. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based upon a review of personnel files, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies. Employee #1 was hired on March 19, 2019 and was still employed at the time of the inspection. There was no documentation in employee # 1 ' s personnel file indicating that the employee had been trained on what to do during emergencies as of the date of this inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director completed this training on 6/7/19 and documentation of this has been placed in his file. All relevant staff within the HR and Training departments will review the DDAP 705.10 (d) (3) regulations by 7/31/19, and as the head of the Training department, the Director of Training and Education will be ultimately responsible for ensuring that all staff (to include administrative staff) receive required emergency procedure training upon hire. Training department staff will review all staff files during the orientation process to ensure that this training is completed.
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709.28 (c) (1) 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. The consent must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency or organization to whom the disclosure is made.
Client # 8 was admitted on July 11, 2019 and was still active at the time of the inspection. The client record had eight informed and voluntary consent forms signed and dated on July 11, 2019 without identifying to whom the release was signed for.
Client # 9 was admitted on July 12, 2019 and was still active at the time of inspection. The client record had five informed and voluntary consent forms signed and dated on July 12, 2019 without identifying to whom the release was signed for.
Client # 14 was admitted on July 15th, 2019 and was still active at the time of inspection. The client record had an informed and voluntary consent form signed and dated on July 15, 2019 without identifying to whom the release was signed for.
Client # 20 was admitted on July 11, 2019 and was still active at the time of inspection. The client record had an informed and voluntary consent form signed and dated on July 11, 2019 without identifying to whom the release was signed for.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
By 8-23-19, on site Program Supervisor will review charts #8, #9, #14 & #20 specifically the release section and will remove and destroy any incomplete release within each chart. Division Director will follow up with Clinical Supervisor at the close of business on 8-23-19 to ensure this task was completed. At the next Coal Township all staff meeting to be held on 9-19-19, Program Director and Program Supervisor will review confidentiality regulations as it relates to the release of information, more specifically documenting the name of person, agency or organization to whom the disclosure will be made. The Program Supervisor and Program Director will
review charts for completeness of release of information during the CQI process monthly. Clinical staff will be monitored monthly in regular supervisory sessions as well as weekly during clinical meeting.
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709.28 (c) (2) 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. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the project failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5
Client #15 was admitted on June 25, 2019 and was discharged on July 16, 2019. An informed and voluntary consent to disclose information was signed and dated on June 25, 2019 to the funding sources, and County Assistance Office that allowed for the disclosure of the treatment plans, case consults, psych assessment, physical/medical record, discharge summary, progress notes and medications records.
Client #17 was admitted on July 8, 2019 and was still active at the time of inspection. An informed and voluntary consent to disclose information was signed and dated on July 3, 2019 to the funding sources, multiple government agencies and an insurance company that allows for the disclosure of admission/discharge paperwork.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The errors in clients #15 & #17 charts were unable to be corrected due to both being discharged prior to cite postings. At the next Coal Township all staff meeting to be held on 9-19-19, Program Director and Program Supervisor will review confidentiality regulations as it relates to informed and voluntary consent to disclose information specifically reviewing the 5 points of release allowed under 255.5. Staff's direct supervisors will add confidentiality training to supervisees individual annual training plans. The Program Supervisor and Program Director will review charts for accurate compliance of release of information during the CQI process monthly. Clinical staff will be monitored monthly in regular supervisory sessions as well as weekly during clinical meeting. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to document that a copy of a client consent shall be offered to the client.
Client # 8 was admitted on July 11, 2019 and was still active at the time of the inspection. A consent to release to a government agency signed on July 11, 2019 did not document if a copy was offered to the client.
Client #10 was admitted on June 28, 2019 and was still active at the time of the inspection. A consent to release to a government agency signed on June 28, 2019 did not document if a copy was offered to the client.
Client #13 was admitted on July 5, 2019 and was discharged July 8, 2019. A consent to release to a government agency signed on July 5, 2019 did not document if a copy was offered to the client.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The errors in clients #8, #10 & #13 charts were unable to be corrected due to being discharged prior to cite postings. At the next Coal Township all staff meeting to be held on 9-19-19, Program Director and Program Supervisor will review release of information compliance standards to include that a copy of the client consent form was offered to each client and either accepted or rejected pending which box the client checks. A copy of the verified release will be kept in each clients chart. The Program Supervisor and Program Director will review charts for accurate compliance of release of information during the CQI process monthly. Clinical staff will be monitored monthly in regular supervisory sessions as well as weekly during clinical meeting. |
709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on a review of 21 client records, the project ' s client rights documentation, which is included in the orientation packet, failed to include all the required client rights including clients have the right to appeal a decision limiting access to their records to the director
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Continuous Quality Improvement Director has revised the Gaudenzia Client Bill of Rights to accurately reflect the DDAP 709.30 regulations regarding a client's right to inspect their own record and actions they make take in this regard. The document now states that, "The following rights are affirmed... The right to examine one's own record within the guidelines approved by the agency in accordance with Federal regulations 42 CFR, and rebut any information in their record by inserting a counter statement of clarification or correction. The agency may temporarily remove portions of the record prior to inspection if the Director determines that the information may be detrimental if presented to the client. Reasons for removal of sections will be documented in the record. Clients have the right to appeal a decision limiting access to their records to the director. Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records." This revised Bill of Rights document will be distributed to all programs by 7/26/19. The Program Director will review it with all staff and it will be incorporated into the client orientation manuals and signed by all active clients by 8/2/19. The Program Director will ensure that as a part of the regular, monthly CQI Chart Audit process, the current version of the Client Bill of Rights is being completed. |
709.30 (5) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Based on a review of 21 client records, the project ' s client rights documentation, which is included in the orientation packet, failed to include all the required client rights including clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Continuous Quality Improvement Director has revised the Gaudenzia Client Bill of Rights to accurately reflect the DDAP 709.30 regulations regarding a client's right to inspect their own record and actions they make take in this regard. The document now states that, "The following rights are affirmed... The right to examine one's own record within the guidelines approved by the agency in accordance with Federal regulations 42 CFR, and rebut any information in their record by inserting a counter statement of clarification or correction. The agency may temporarily remove portions of the record prior to inspection if the Director determines that the information may be detrimental if presented to the client. Reasons for removal of sections will be documented in the record. Clients have the right to appeal a decision limiting access to their records to the director. Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records." This revised Bill of Rights document will be distributed to all programs by 7/26/19. The Program Director will review it with all staff and it will be incorporated into the client orientation manuals and signed by all active clients by 8/2/19. The Program Director will ensure that as a part of the regular, monthly CQI Chart Audit process, the current version of the Client Bill of Rights is being completed. |
709.30 (6) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on a review of 21 client records, the project ' s client rights documentation, which is included in the orientation packet, failed to include all the required client rights including clients have the right to submit rebuttal data or memoranda to their own records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Continuous Quality Improvement Director has revised the Gaudenzia Client Bill of Rights to accurately reflect the DDAP 709.30 regulations regarding a client's right to inspect their own record and actions they make take in this regard. The document now states that, "The following rights are affirmed... The right to examine one's own record within the guidelines approved by the agency in accordance with Federal regulations 42 CFR, and rebut any information in their record by inserting a counter statement of clarification or correction. The agency may temporarily remove portions of the record prior to inspection if the Director determines that the information may be detrimental if presented to the client. Reasons for removal of sections will be documented in the record. Clients have the right to appeal a decision limiting access to their records to the director. Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records." This revised Bill of Rights document will be distributed to all programs by 7/26/19. The Program Director will review it with all staff and it will be incorporated into the client orientation manuals and signed by all active clients by 8/2/19. The Program Director will ensure that as a part of the regular, monthly CQI Chart Audit process, the current version of the Client Bill of Rights is being completed. |
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 21 client records, the project failed to notify the client, in writing, of the decision to involuntarily terminate the client ' s treatment at the project in two of four applicable record reviewed.
Client #18 was admitted on June 14, 2019 and was administratively discharged on June 28, 2019.
Client#21 was admitted on June 20, 2019 and was administratively discharged on June 26, 2019.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective August 1, 2019 Program Supervisor directed all clinical staff that each involuntary termination of a client's treatment required a written notification of termination be mailed to the client. Each notice shall include the reason for termination as well as grievance and appeal process information. Both client #18 and #21 will be sent the appropriate termination notice from their clinician by August 23, 2019. Program Supervisor will follow up with assigned clinicians at the close of business on 8-23-19 to ensure this task was completed. The Program Supervisor and Program Director will review charts for completion of termination notifications during the CQI process monthly. Clinical staff will be monitored monthly in regular supervisory sessions as well as weekly during clinical meeting. |
709.62(c)(3)(i) LICENSURE Medical history
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records, the facility failed to document a medical history in three client records.
Client #10 was admitted on June 28, 2019 and was discharged on July 3, 2019. There was no documentation of a medical history in the client file.
Client #13 was admitted on July 5, 2019 and was discharged on July 8, 2019. There was no documentation of a medical history in the client file.
Client #14 was admitted on July 15, 2019 and was still active at the time of inspection. There was no documentation of a medical history in the client file.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective August 1, 2019 the Nursing Supervisor directed all nursing staff during supervisory sessions that a medical history needed to be completed in each client file. Client #10, #13 & #14 were all discharged prior to this supervisory direction. Nursing Supervisor will monitor client charts for compliance weekly and review findings during weekly nursing meetings. |
709.62(c)(3)(ii) LICENSURE D & A History
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of client records, the facility failed to document a drug or alcohol history, or both in the three client records.
Client #10 was admitted on June 28, 2019 and was discharged on July 3, 2019. There was no documentation of a drug and alcohol history in the client file.
Client #13 was admitted on July 5, 2019 and was discharged on July 8, 2019. There was no documentation of a drug and alcohol history in the client file.
Client #14 was admitted on July 15, 2019 and was still active at the time of inspection. There was no documentation of a drug and alcohol history in the client file.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On July 31, 2019 Gaudenzia's new bio-psychosocial was activated in the EHR (electronic health records system) which include a thorough drug and alcohol history. Clients #10, #13 & # 14 were all discharged prior to the rollout. Program Supervisor directed clinical staff on August 1, 2019 to begin utilizing the new document. At the next Coal Township all staff meeting to be held on 9-19-19, Program Director and Program Supervisor will remind all staff to complete a thorough D & A history. The Program Supervisor and Program Director will review charts for completeness of D & A history during the CQI process monthly. Clinical staff will be monitored monthly in regular supervisory sessions as well as weekly during clinical meeting. |
709.62(c)(3)(iii) LICENSURE Personal history
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records, the facility failed to document personal history in the three client records.
Client #10 was admitted on June 28, 2019 and was discharged on July 3, 2019. There was no documentation of personal history in the client file.
Client #13 was admitted on July 5, 2019 and was discharged on July 8, 2019. There was no documentation of personal history in the client file.
Client #14 was admitted on July 15, 2019 and was still active at the time of inspection. There was no documentation of personal history in the client file.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On July 31, 2019 Gaudenzia's new bio-psychosocial was activated in the EHR (electronic health records system) which include a thorough personal history. Clients #10, #13 & # 14 were all discharged prior to the rollout. Program Supervisor directed clinical staff on August 1, 2019 to begin utilizing the new document. At the next Coal Township all staff meeting to be held on 9-19-19, Program Director and Program Supervisor will remind all staff to complete a thorough personal history. The Program Supervisor and Program Director will review charts for completeness of personal history during the CQI process monthly. Clinical staff will be monitored monthly in regular supervisory sessions as well as weekly during clinical meeting. |
709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a biopsychosocial evaluation in the three client records.
Client #10 was admitted on June 28, 2019 and was discharged on July 3, 2019. There was no documentation of a biopsychosocial evaluation in the client file.
Client #13 was admitted on July 5, 2019 and was discharged on July 8, 2019. There was no documentation of a biopsychosocial evaluation in the client file.
Client #14 was admitted on July 15, 2019 and was still active at the time of inspection. There was no documentation of a biopsychosocial evaluation in the client file.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On July 31, 2019 Gaudenzia's new bio-psychosocial was activated in the EHR (electronic health records system). Clients #10, #13 & # 14 were all discharged prior to the rollout. Program Supervisor directed clinical staff on August 1, 2019 to begin utilizing the new document. At the next Coal Township all staff meeting to be held on 9-19-19, Program Director and Program Supervisor will remind all staff to complete the biopsychosocial. The Program Supervisor and Program Director will review charts for completeness of biopsychosocial during the CQI process monthly. Clinical staff will be monitored monthly in regular supervisory sessions as well as weekly during clinical meeting. |
709.53(a) LICENSURE Complete Client Record
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:
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Observations
Based on a review of client records, the project failed to provide a complete client record, which is to include verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
Client#18 was admitted on June 14, 2019 and was discharged on June 28, 2019. There was no documentation in the client record verifying that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
Client #20 was admitted on July 11, 2019 and was still active at the time of discharge. There was no documentation in the client record verifying that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
Client #21 was admitted on June 20, 2019 and was discharged on June 26, 2019. There was no documentation in the client record verifying that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #20 & #21 were both still on their blackout orientation phase and would not have been assigned a job function. Effective August 1, 2019 Program Supervisor directed clinical staff to document all job functions in each clients chart as it relates to the therapeutic process, treatment goals and recovery. At the next Coal Township all staff meeting to be held on 9-19-19, Program Director and Program Supervisor will remind all staff to document client job functions in the client chart. The Program Supervisor and Program Director will review charts for compliance during the CQI process monthly. Clinical staff will be monitored monthly in regular supervisory sessions as well as weekly during clinical meeting.
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709.92(c) LICENSURE Treatment and rehabilitation services
709.92. 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 the review of client records, the facility failed to assure that counseling services were provided according to the individual treatment and rehabilitation plans in five out of seven records reviewed.
Client # 1 was admitted on 03/29/2019 and was still an active client at the time of the inspection. Treatment plans dated 03/29/2019 and 04/29/2019 indicated that the client was to receive individual counseling sessions weekly. Individual counseling session were not documented for this client during the weeks of 04/01/2019, 04/08/2019, 04/15/2019, 04/29/2019, 05/06/19, 05/20/2019, 05/27/2019, 06/03/2019, 06/10/2019, 06/17/2019, 06/24/2019, 07/1/2019 and 07/8/2019. Only three documented attempts were made to engage client in treatment; 05/28/2019, 06/25/2019 and 06/28/2019. The last time any documented attempts were made to contact the client was on 06/28/2019.
Client #2 was admitted on 02/07/2019 and was still an active client at the time of the inspection. A treatment plan dated 03/22/2019 indicated that the client was to receive individual counseling biweekly and group counseling sessions weekly. Individual counseling sessions are not documented as occurring biweekly. There is no documentation that the client attended group counselling sessions the week of 03/25/2019 and 04/08/2019. A treatment plan dated 05/22/2019 indicated that the client is to receive group counseling and individual counselling session biweekly. There is no documentation that the client attended any group counseling sessions between 05/27/2019 through 06/28/2019. The client last attended a group therapy session on 06/28/2019.
Client #3 was admitted on 05/20/2019 and was still an active client at the time of the inspection. Treatment plans dated 04/29/2019 and 05/20/2019 indicated that the client was to receive individual counseling sessions and group counseling sessions weekly. Individual counseling sessions were not documented for this client during the weeks of 05/06/2019, 05/13/2019, 06/17/2019 and 07/08/2019. Two attempts were made to engage this client in treatment; 06/19/2019 and 06/20/2019. One group counseling session was documented for this client that occurred on 06/28/2019.
Client # 6 was admitted on 03/12/2019 and was still an active client at the time of the inspection. Treatment plans dated 03/04/2019, 04/02/2019 and 06/02/2019 indicated that the client was to receive individual counseling sessions weekly. Individual counseling sessions were not documented for the weeks of 03/25/2019, 04/08/2019, 04/22/2019, 05/06/2019, 05/20/2019, 06/03/2019 and 06/17/2019.
Client #7 was admitted on 05/15/2019 and discharged 07/10/2019. Treatment plans dated 05/15/2019, 06/14/2019 and 07/10/2019 indicated that the client was to receive individual counselling sessions and group counseling sessions weekly. Individual counseling sessions were not documented for the weeks of 05/27/2019 and 07/01/2019. There is no documentation that this client ever attended any group counseling sessions.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An all staff in service training will be held on Sept 13, 2019 to address clinical staff on treatment management procedures specific to assuring that counseling services are provided according to the individual and treatment plan
updates. All staff will be directed to schedule clients according to their treatment recommendation and document weekly on the client record of service. Any deviation from the set course of treatment will
also be documented on the record of
service. The Clinical Supervisor and Division Director will
review treatment plans
recommendations and compare it to
the record of service for compliancy
during the CQI process monthly.
Clinical staff will be monitored
monthly in regular supervisory
sessions as well as weekly during
clinical meeting.
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