INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 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. Vantage House 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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709.24 (a) LICENSURE Treatment/rehabilitation Management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
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Observations
Based on a review of client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients in two of three applicable records reviewed.
Client #5 was admitted to residential rehabilitation level of care on November 9, 2023 and discharged against facility advice on February 24, 2024. The facility failed to follow their policy related to against facility advice discharges of calling the emergency contact within twelve hours.
Client #6 was admitted to residential rehabilitation level of care on February 23, 2024 and discharged against facility advice on April 16, 2024. The facility failed to follow their policy related to against facility advice discharges of calling the emergency contact within twelve hours.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will review the associated regulation with all clinical and support staff, reminding them that the client's designated emergency contact must be notified within 12 hours of any discharge against facility advice.
Staff on duty at the time of any client discharge against facility advice will also promptly notify the Program Director of such and document emergency contact in the client record. Training will be provided as needed.
The Program Director, Clinical Supervisor, and Continued Quality Improvement Staff will monitor ongoing conformance via chart audits at least monthly. Any issues noted will be addressed with the clinician in a documented clinical supervision session and corrected immediately.
Target Date: 5/24/24
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709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records, the facility failed to ensure that annual written individual staff performance evaluations, were reviewed and signed by the employee per the facility ' s policy and procedure manual in two out of three personnel records reviewed. The facility ' s policy and procedure manual states that the annual job performance evaluations are due at the beginning of each calendar year. Project staff indicated evaluations specifically are to be completed and signed by February 1 each year.
Employee #1 was hired on September 9, 2019 as the project director and is still in that position at the time of the inspection The annual work performance evaluation was not completed until February 28, 2024.
Employee #4 was hired on September 28, 2020 as a counselor and is still in that position at the time of the inspection. The annual work performance evaluation was not completed until February 7, 2024.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
All Gaudenzia Managers will ensure that Annual Performance Evaluations are completed, reviewed with the employee during a documented supervision session, and acknowledged via signature by both parties no later than February 1st of each year.
The Chief Executive Officer will ensure that this process is completed for the Project Director.
The Deputy Director will ensure that this process is completed for the Program Directors that they oversee, and will also ensure that these Program Directors complete Annual Performance Evaluations for the staff that they oversee.
The Quality Assurance department will review staff files during semi-annual program reviews to ensure compliance.
Target Date: 2/1/25
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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 the review of client records, the facility failed to document a complete psychosocial evaluation per the facility ' s policy and procedure manual in six out of seven applicable records. The facility ' s policy states a psychosocial evaluation is completed within thirty days of admission.
Client #1 was admitted on December 8, 2023 and was still active at the time of the inspection. A psychosocial evaluation was due no later than January 8, 2024; however, there was no documentation that a psychosocial evaluation was completed.
Client #2 was admitted on February 24, 2024 and was still active at the time of the inspection. A psychosocial evaluation was due no later than March 24, 2024; however, there was no documentation that a psychosocial evaluation was completed.
Client #3 was admitted on November 19, 2023 and was still active at the time of the inspection. A psychosocial evaluation was due no later than December 19, 2023; however, there was no documentation that a psychosocial evaluation was completed.
Client #5 was admitted on November 9, 2023 and discharged on February 24, 2024. A psychosocial evaluation was due no later than December 9, 2023; however, there was no documentation that a psychosocial evaluation was completed.
Client #6 was admitted on February 23, 2024 and discharged on April 16, 2024. A psychosocial evaluation was due no later than March 23, 2024; however, there was no documentation that a psychosocial evaluation was completed.
Client #7 was admitted on November 17, 2023 and discharged on January 17, 2024. A psychosocial evaluation was due no later than December 17, 2023; however, there was no documentation that a psychosocial evaluation was completed.
This is a repeat citation from the May 31, 2023 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will meet with all clinical staff and review applicable regulations, reminding them that the client's psychosocial evaluation must be completed within 30 days of admission, in accordance with agency policy.
Training will be provided as needed.
Clinical staff meetings will review staff tracking strategies and monitor completion of required documentation weekly. The Program Director, Clinical Supervisor, and Continued Quality Improvement Staff will monitor ongoing conformance via chart audits at least monthly. Any issues noted will be addressed with the clinician in a documented clinical supervision session and corrected immediately.
Target Date: 5/24/24
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709.52(c) LICENSURE Provision of Counseling Services
709.52. 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 a review of client records, the facility failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan in six out of seven records reviewed.
Client #1 was admitted on December 8, 2023 and was still active at the time of the inspection. A treatment plan dated December 11, 2023, indicated individual counseling one time per week. There was no documentation that the client received individual counseling the weeks of December 18, 2023, January 1, 22, February 5, 12, 19, 26, March 11, 18, 25 and April 8, 2024.
Client #2 was admitted on February 24, 2024 and was still active at the time of the inspection. The treatment plan dated March 2, 2024, indicated individual counseling one time per week. There was no documentation that the client received individual counseling the weeks of March 4, 11, 18, 25, and April 8, 2024.
Client #3 was admitted on November 19, 2023 and was still active at the time of the inspection. The treatment plan dated February 1, 2024, indicated individual counseling one time per week. There was no documentation that the client received individual counseling the weeks of February 5, 12, 19, March 11, 18, 25, and April 11, 2024.
Client #4 was admitted on October 16, 2023 and discharged on March 4, 2023. The treatment plan dated January 3, 2024, indicated individual counseling one time per week. There was no documentation that the client received individual counseling the weeks of January 8, 15, 22, 29, February 5, 12 and 19, 2024.
Client #5 was admitted on November 9, 2023 and discharged on February 24, 2024. The treatment plan dated January 13, 2024, indicated individual counseling one time per week. There was no documentation that the client received individual counseling the weeks of January 15, 22, 29, February 12, and 19, 2024.
Client #6 was admitted on February 23, 2024 and discharged on April 16, 2024. The treatment plan dated March 3, 2024, indicated individual counseling one time per week. There was no documentation that the client received individual counseling the weeks of March 4, 11, 18, 25, and April 1, 8, 2024.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Program Director will review associated regulations with all clinical staff, to ensure that counseling services are provided according to the treatment and rehabilitation plan. Counseling frequency will be noted on the treatment plan and delivery of counseling will be documented for each service and entered in the client record as per organization policy. Training will be provided as needed.
Clinical staff meetings will review staff tracking strategies and monitor completion of required documentation weekly. The Program Director, Clinical Supervisor, and Continued Quality Improvement Staff will monitor ongoing conformance via chart audits at least monthly. Any issues noted will be addressed with the clinician in a documented clinical supervision session and corrected immediately.
Target Date: 5/24/24
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709.53(a)(9) LICENSURE Aftercare plans
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:
(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 an aftercare plan within guidelines established by the facility ' s policy and procedure manual in two out of four discharged records reviewed. The facility ' s policy and procedure manual states the aftercare is completed prior to discharge.
Client #4 was admitted on October 16, 2023 and discharged on March 4, 2023. There was no documentation that an aftercare plan was completed.
Client #5 was admitted on November 9, 2023 and was discharged on February 24, 2024. There was no documentation that an aftercare plan was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will meet with all clinical staff to ensure that aftercare plans are completed before discharge and documented in the client record as per agency policy. Review of regulation and training will be provided as needed.
Weekly clinical staff meetings will review staff tracking and monitor completion of required documentation. The Program Director, Clinical Supervisor, and Continued Quality Improvement Staff will monitor ongoing conformance via chart audits at least monthly. Any issues noted will be addressed with the clinician in a documented clinical supervision session and corrected immediately.
Target Date: 5/24/24
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709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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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 a discharge summary within guidelines established by the facility ' s policy and procedure manual in two out of four discharged records reviewed. The facility ' s policy and procedure manual states the discharge summary is completed within seven days of discharge.
Client #4 was admitted on October 16, 2023 and was discharged on March 4, 2024. A discharge summary was due no later than March 11, 202; however, there is no documentation that one was completed.
Client #5 was admitted on November 9, 2023 and was discharged on February 24, 2024. A discharge summary was due no later than March 3, 2024; however, there is no documentation that one was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will review with all clinical staff, the applicable regulation requiring a written discharge summary be included in the client record, as well as the agency policy requiring submission of such within seven days. Training will be provided as needed.
Weekly clinical staff meetings will review staff tracking and monitor completion of required documentation. The Program Director, Clinical Supervisor, and Continued Quality Improvement Staff will monitor ongoing conformance via chart audits at least monthly. Any issues noted will be addressed with the clinician in a documented clinical supervision session and corrected immediately.
Target Date: 5/24/24
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709.53(a)(11) LICENSURE Follow-up information
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:
(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 guidelines established by the facility ' s policy and procedure manual in two out of three applicable discharged records reviewed. The facility ' s policy and procedure manual states the follow up is completed within seven days of discharge.
Client #4 was admitted on October 16, 2023 and discharged on March 4, 2024. A follow up was due no later than March 11, 2024; however, it was not completed until March 16, 2024.
Client #5 was admitted on November 9, 2023 and discharged on February 24, 2024. A follow up was due no later than March 2, 2024; however, it was not completed until March 5, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will review the regulations around follow-up information being documented by clinical and/or support staff in the client record within seven days as per agency policy. Training will be provided as needed.
Weekly administrative and clinical staff meetings will monitor completion of required documentation. The Program Director, Clinical Supervisor, and Continued Quality Improvement Staff will monitor ongoing conformance via chart audits at least monthly. Any issues noted will be addressed with the clinician in a documented clinical supervision session and corrected immediately.
Target Date: 5/24/24
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