INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 23, 2024, 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. Harrisburg Concept 90 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)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee # 5 and # 7 received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #5 was hired as a counselor on January 3, 2023, and was still in this position at the time of the inspection. Employee # 5 was due to have the communicable disease trainings no later than January 3, 2024, however, there was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee # 7 was hired as a support staff on October 26, 2021, and was still in this position at the time of the inspection. Employee # 7 was due to have the communicable disease trainings no later than October 26, 2023, however, there was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection and HIV/AIDS training was not completed until May 28, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee # 5 is no longer employed with Gaudenzia as of 5/29/24. Employee # 7 completed TB/STD training on 4/12/24 for a total 4 hrs. The Program Director and Administrative Coordinator will review all staff training records monthly to assure training compliance and provide staff with monthly updates on training needed to be in compliance. The Quality Assurance manager will conduct semiannual audits that include reviewing the training records of the staff. The report will include a list of the trainings staff members have yet to complete. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Cameras were located in group rooms.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Gaudenzia has been granted a DDAP exception waiver to 705.4 (3) allowing video-only recording strictly for safety and security purposes in the common areas of the program, including areas which may be used for group sessions. This exception waiver was granted as of 6/18/24.
Gaudenzia is adding language to our consent forms to obtain informed consent from all clients to allow video-only recording strictly for safety and security purposes in the common areas of the program, including areas which may be used for group sessions. This language will be added to the consent forms no later than 6/30/24 and will then be reviewed and signed by all current clients prior to their next counseling session.
In the interim, the program will disable any camera which is positioned in such a way as to capture video of any counseling session. These cameras will be enabled once all clients have signed the consents, no later than 7/12/24. |
705.7 (b) (3) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(3) Clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
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Observations
Based on a physical plant inspection, the facility failed to keep cooking and eating utensils in a clean and enclosed area. Cooking utensils were being stored hanging in an open area in the kitchen. Plasticware was being stored in the cafeteria in bins that were not covered.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The plasticware is now being covered with saran wrap. The cook will place all hanging cookware in enclosed cabinets. The cook will be responsible for assuring these items are appropriately stored at the end of their shift daily. The program director and Administrative Coordinator will ensure compliance at least once a month during safety inspections. Any area of non- compliance will be brought to the cook's attention and be corrected immediately. |
705.10 (c) (2) (ii) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(2) Maintain at least one portable fire extinguisher with a minimum of an ABC rating in each kitchen.
(ii) The extinguisher shall be located near an exit and away from the cooking area.
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Observations
Based on a physical plant inspection, the facility failed to maintain the fire extinguisher in the kitchen near the exit. Instead, it was located on the far wall opposite the exit.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Maintenance has installed the fire extinguisher near the exit in the kitchen. Placement will be monitored during documented monthly safety checks by the Program Director. |
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 one of eight client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
Client # 4 was admitted on March 18, 2024, and was still active at the time of the inspection. There was not a consent for a funding source documented in the record. Facility staff acknowledged billing was occurring.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the May 24, 2023, annual licensing inspection.
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Plan of Correction
The Program Director/Clinical Supervisor will review the workflow which includes completing a consent form for the client's funder with appropriate staff by June 20, 2024. The Utilization Review staff will ensure consents are signed by members for the funder prior to any continued stay reviews and billing. If they do not find a consent to release information in the client's chart, the Utilization Review staff will inform the clinician to complete one within 24 hours. The Clinical Supervisor will verify consents have been signed during weekly chart audits. The Program Director will review for compliance during bi-monthly audits
The Quality Assurance Manager will audit for compliance during their semi-annual audit reviews and relay the findings to the Program Director and Clinical Supervisor.
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709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the purpose of the disclosure related to the entity information was being disclosed to.
Client # 1 was admitted on March 20, 2024, and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated May 7, 2024, to a recovery house stated the specific purpose of the release was for funding, however the recovery house was not the client ' s funding source.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director/Clinical Supervisor will review how to complete consents accurately to include the purpose of the release with all staff by June 20, 2024. The Clinical Supervisor will verify consents have been completed appropriately during weekly chart audits. The Program Director will review for compliance during bi-monthly audits. The Quality Assurance Manager will audit for compliance during their semiannual audit reviews and relay the findings to the Program Director and Clinical Supervisor. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on a review of the facility policy and procedure manual and physical plant, the drug storage area and medications shall be inspected by an assigned nurse or designated trained staff member at least quarterly. The Medication and Drug Storage Inspection form shall be completed quarterly by the individual conducting the inspection and by the nurse manager or program director who accompanies him/her during the inspection. The facility was not documenting inspections of the drug area and medications at least quarterly.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will complete quarterly inspections of the medication area with the nurse on duty and document on The Medication and Drug Storage Inspection form with the first occurring by 6/21/24. This form will be kept in a binder in the medical office.
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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 a review of the unusual incident reports, the facility failed to report to the Department, within three business days, an incident that involved a physical assault by a client. The incident occurred on February 20, 2024, however, was not reported to the department until March 4, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon approving an internal incident report, the Program Director, with the assistance of the Administrator will ensure required incident reports are submitted to DDAP within three business days. The Program Director will review incident reporting with all staff at the June 20, 2024 all staff meeting. CQI will review incident reports for timely submission during their semi-annual audits
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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 a review of the unusual incident reports, the facility failed to report to the Department, within three business days, an incident that involved the requirement of police personnel at the facility. The incident occurred on February 20, 2024, however, was not reported to the department until March 4, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon approving an internal incident report, the Program Director, with the assistance of the Administrator will ensure required incident reports are submitted to DDAP within three business days via the DDAP ERS Portal. The Program Director will review incident reporting with all staff at the June 20, 2024 all staff meeting. CQI will review incident reports for timely submission during semi-annual audits.
The Program Director will assure compliance. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on four of eight applicable client records reviewed, the facility failed to provide a psychosocial evaluation in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicated a psychosocial evaluation be completed within five days of admission and include a narrative psychosocial assessment. The assessment shall include a client description, the referral source, presenting and underlying problems, treatment issues, client coping mechanisms, factors contributing to addiction, client strengths and weaknesses, client motivation, support system, client response during the intake, receptivity to treatment and client attitude, ability to participate in treatment, client motivation, support systems, treatment recommendations, diagnosis, and prognosis. Emphasis is placed on the documentation of the client ' s strengths, abilities, and preferences (SNAP).
Client # 1 was admitted on March 20, 2024, and was still active at the time of the inspection. The biopsychosocial evaluation did not include the narrative psychosocial assessment required by the facility policy and procedure manual.
Client # 4 was admitted on March 18, 2024, and was still active at the time of the inspection. The biopsychosocial evaluation did not include the narrative psychosocial assessment required by the facility policy and procedure manual.
Client # 5 was admitted on September 20, 2023, and was discharged January 4, 2024. The biopsychosocial evaluation did not include the narrative psychosocial assessment required by the facility policy and procedure manual.
Client # 7 was admitted on December 12, 2023, and was discharged February 12, 2024. The biopsychosocial evaluation did not include the narrative psychosocial assessment required by the facility policy and procedure manual.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the May 24, 2023, annual licensing inspection.
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Plan of Correction
The Clinical Supervisor will train Clinical staff in how to complete interpretive summaries (narrative assessments) by June 19,2024. The Clinical Supervisor shall ensure interpretive summaries (narrative assessments) are included prior to the approval of Biopsychosocial forms. CQI will also review documents for narratives in their semi-annual audits. |
709.52(a)(2) LICENSURE Tx type & frequency
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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on seven of eight applicable client records reviewed, the facility failed to provide an individual treatment and rehabilitation plan developed with the client to include the frequency groups.
Client # 1 was admitted on March 20, 2024, and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on March 26, 2024, and updated on April 26 and May 21, 2024, however, there was no documentation of frequency of groups provided.
Client # 2 was admitted on April 19, 2024, and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on April 25, 2024, and updated on May 22, 2024, however, there was no documentation of frequency of groups provided.
Client # 4 was admitted on March 18, 2024, and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on March 18, 2024, and updated on April 22, 2024, however, there was no documentation of frequency of groups provided.
Client # 5 was admitted on September 20, 2023, and was discharged January 4, 2024. A comprehensive treatment and rehabilitation plan was developed with the client on September 29, 2023, however, there was no documentation of frequency of groups provided.
Client # 6 was admitted on January 23, 2024, and was discharged February 13, 2024. A comprehensive treatment and rehabilitation plan was developed with the client on January 24, 2024, however, there was no documentation of frequency of groups provided.
Client # 7 was admitted on December 12, 2023, and was discharged February 12, 2024. A comprehensive treatment and rehabilitation plan was developed with the client on December 15, 2023, and updated on December 26, 2023, and February 5, 2024, however, there was no documentation of frequency of groups provided.
Client # 8 was admitted on March 19, 2024, and was discharged April 7, 2024. A comprehensive treatment and rehabilitation plan was developed with the client on March 22, 2024, however, there was no documentation of frequency of groups provided.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will provide training to the clinical team on documentation for group frequency on the treatment plan.
On a weekly basis the Clinical Supervisor will review at least two member records per counselor to ensure the frequency of groups is listed on the treatment plan. If the frequency is not found, the Clinical Supervisor will review this during clinical supervision and the treatment plan will be updated within 48 hours. The Program Director will ensure compliance in bi-monthly audits. CQI will ensure compliance in semiannual audits. |
709.53(a)(5) LICENSURE Progress 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:
(5) Progress notes.
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Observations
Based on seven of eight client records reviewed, the facility failed to provide a complete client progress note to reflect the clinician ' s assessment of the client ' s progress in treatment, per facility policy.
Client # 1 was admitted on March 20, 2024, and was still active at the time of the inspection. Group notes documented on April 9 and May 21, 2024, did not include the clinician ' s assessment of the client ' s participation in the group sessions.
Client # 2 was admitted on April 19, 2024, and was still active at the time of the inspection. A group note documented on May 15, 2024, did not include the clinician ' s assessment of the client ' s participation in the group session.
Client # 3 was admitted on April 1, 2024, and was still active at the time of the inspection. Group notes documented on May 15, 16, and 22, 2024, did not include the clinician ' s assessment of the client ' s participation in the group sessions.
Client # 4 was admitted on March 18, 2024, and was still active at the time of the inspection. Group notes documented on May 8, 15, and 16, 2024, did not include the clinician ' s assessment of the client ' s participation in the group sessions.
Client # 5 was admitted on September 20, 2023, and was discharged January 4, 2024. A group note on January 2, 2024, did not include the clinician ' s assessment of the client ' s participation in the group session.
Client # 6 was admitted on January 23, 2024, and was discharged February 13, 2024. Group notes documented on January 31, February 1, and 6, 2024, did not include the clinician ' s assessment of the client ' s participation in the group sessions.
Client # 7 was admitted on December 12, 2023, and was discharged February 12, 2024. Group notes documented on January 26, 31, February 1, and 6, 2024, did not include the clinician ' s assessment of the client ' s participation in the group sessions.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will provide training on completing group session assessments on the group progress note with the clinical team by June 19, 2024 The Clinical Supervisor will ensure assessments are completed on group notes through a review of two group notes per clinician each week. Program Director will assure assessments are completed on group notes through a review of two group notes per clinician bi-monthly. CQI will ensure assessments are completed on group notes during semi-annual audits. |
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 five of eight applicable client records reviewed, the facility failed to provide case consultations in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a case consultation to occur within fifteen days.
Client # 1 was admitted on March 20, 2024, and was still active at the time of the inspection. A case consultation was due to occur no later than April 4, 2024, however, it did not occur until April 18, 2024.
Client # 4 was admitted on March 18, 2024, and was still active at the time of the inspection. A case consultation was due to occur no later than April 2, 2024, however, it did not occur until April 26, 2024.
Client # 6 was admitted on January 23, 2024, and was discharged February 13, 2024. A case consultation was due to occur no later than February 7, 2024, however, it did not occur until February 13, 2024.
Client # 7 was admitted on December 12, 2023, and was discharged February 12, 2024. A case consultation was due to occur no later than December 27, 2023, however, it did not occur until February 2, 2024.
Client # 8 was admitted on March 19, 2024, and was discharged April 7, 2024. A case consultation was due to occur no later than April 3, 2024, however, one did not occur.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will provide training on timely documentation as it relates to case consults to the clinical team by June 19, 2024, The Clinical Supervisor will monitor case consultation completion weekly via a spreadsheet that is shared with clinical staff. The Program Director will review charts for timely case consult completion during a bi-monthly audit. CQI will review a sample of charts for timely case consults in semiannual audits.
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