INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 6, 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. Fulton County Outpatient 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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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, to complete within 30 days of admission, in five out of seven records reviewed. Client #1 was admitted on April 5, 2023 and still active at the time of the inspection. A comprehensive treatment plan was due no later than May 5, 2023; however, was completed on May 17, 2023.Client #2 was admitted on November 3, 2022 and still active at the time of the inspection. A comprehensive treatment plan was due no later than December 3, 2022; however, was completed on December 7, 2022. Client #5 was admitted on January 6, 2023 and discharged on May 16, 2023. A comprehensive treatment plan was due no later than February 6, 2023; however, was completed on February 21, 2023. Client #6 was admitted on June 14, 2022 and discharged on September 21, 2022. A comprehensive treatment plan was due no later than July 14, 2022; however, was completed on July 21, 2022.Client #7 was admitted on August 11, 2022 and discharged on March 6, 2023. A comprehensive treatment plan was due no later than September 11, 2022; however, was completed on October 12, 2022. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A Clinical Meeting is scheduled for July 11th, 2023. During this meeting, the Division Director will review the policy that Comprehensive Treatment Plans need to be completed within 30 days of admission. The meeting will also include review using the Clinical Forms Audit that is located in the Electronic Health Record that can be used as a guide to monitor due dates of forms based on admission date.
Ongoing compliance will occur through monthly chart audits completed by the Division Director as well as quarterly chart audits completed by CQI Manager. Additional concerns will be managed through supervision with specific counselor as needed. |
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 in one out of two applicable discharged records reviewed.Client #7 was admitted on August 11, 2022 and discharged on March 6, 2023. This is a repeat citation from the May 26, 2021 and April 27, 2022 licensing inspections. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On July 3rd, 2023, the Division Director has set up a meeting with the Administrative Assistant at Fulton County to discuss completing follow up contact notes starting July 1st 2023. The meeting will include demonstrating using the new widget that has been added to the Electronic Health Record that lists the follow ups that are needed.
Division Director will monitor success of this transition ongoing by not only reviewing the completion of the follow up contact note during monthly chart audits, but also by reviewing the report "Details of Discharge" on a weekly basis that shows completion of follow up contact notes for the next 2 months, ending August 31st, 2023.
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709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department. A plan of correction for completing and documenting follow-up information for the outpatient records was submitted and approved by the Department for the May 26, 2021, and April 27, 2022 annual licensing inspections. Completing and documenting follow-up information was again found to be a deficiency in the June 6, 2023 licensing inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A meeting occurred on June 28th, 2023 that included this writer, Division Director, Corporate OP Director and CQI Manager for this region. It was determined in that meeting 10% of charts audited by both the Corporate OP Director and the CQI Manager will be discharged clients. This begin July 2023 and continue on throughout this year's inspection period. This additional layer of correction will monitor the compliance of the Division Director who manages the POC at the facility level. The success or failure of the POC will be reviewed monthly during supervision provided by the Corporate OP Director with the Division Director. |