INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 2, 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 Kindred 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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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 four personnel records, the facility failed to ensure that each staff was instructed in the use of the fire extinguishers upon employment in one applicable record reviewed.
Employee # 2 was hired as the Facility Director on March 27, 2023 and was due to be trained in the use of fire extinguishers upon employment; however, fire safety training was not documented as complete until April 20, 2023.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 6/3/23 the Program Director will ensure all new employees are enrolled in fire safety training within one week of their date of hire. Both Program Director and the Division Director will be responsible for enrolling all staff in this required training. The Program Director will also report the use of the fire extinguishers to the Fire Safety Officer Division Director. |
709.24 (a) (3) 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:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of seven client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients in two of two applicable records reviewed.
Client # 1 was admitted on July 11, 2022 and was discharged Against Staff Advice (ASA) on November 20, 2022. The facility failed to follow their policy related to ASA discharges of calling the Emergency Contact within twelve hours.
Client # 4 was admitted on September 23, 2022 and was discharged Against Staff Advice (ASA) on January 11, 2023. The facility failed to follow their policy related to ASA discharges of calling the Emergency Contact within twelve hours.
This is a repeat citation from the June 23, 2022 annual licensing inspection.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
As of 6/23/23, the Program Director will implement quarterly in-service training days to educate staff on how to incorporate written notification of self-discharging for member discharging Against Staff Advice (ASA). Furthermore, the Program Director will review documentation daily to ensure that written notification of self-discharging practices is adequate. |
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 a review of seven client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in two records reviewed.
Client # 4 was admitted on September 23, 2022 and was discharged on January 11, 2023. The record contained documentation of information regarding presence in treatment to a probation officer on January 10, 2023, to whom there was no client signed consent to release information form.
Client # 7 was admitted on February 23, 2023 and was active at the time of the inspection. The consent to release information form to the funding source was not signed until March 15, 2023, and there was evidence of billing prior to the client signed consent to release information form.
This is a repeat citation from the June 23, 2022, June 2, 2021, and September 24, 2020 annual licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 7/3/23, the Program Director will facilitate an in-service training day dedicated to educating staff on the consent and release of member information. The Program Director will ensure that all clinical documentation/charts are reviewed weekly with a focus on consent and the release of documents. The Quality Assurance Department will also implement quarterly and annual in-house inspections to ensure that corrective measures are enlisted. |
709.51(b)(7) LICENSURE Preliminary Tx. Plan.
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records and the facility's policies and procedures, the facility failed to document a preliminary treatment plan within five days of admission, in three of seven applicable records reviewed.
Client # 2 was admitted on November 11, 2022 and was discharged on February 28, 2023. The preliminary treatment plan was not completed until February 1, 2023.
Client # 6 was admitted on November 14, 2022 and was active at the time of the inspection. The preliminary treatment plan was not completed until November 28, 2022.
Client # 7 was admitted on February 23, 2023 and was active at the time of the inspection. The preliminary treatment plan was not completed until March 2, 2023.
These finding were discussed with facility staff during the licensing process.
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Plan of Correction
The Program Director will conduct an in-service training meeting with the clinical team by 7/6/23. Weekly chart audits will also be implemented and conducted by the Program Director. In addition, the Quality Assurance Department will monitor clinical documentation for compliance and implement clinical reviews to measure the compliance and performance of corrective action plans. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of seven client records, the facility failed to document treatment plan updates within the regulatory timeframe in three of five applicable records reviewed.
Client # 3 was admitted on July 25, 2022 and was discharged on April 5, 2023. A treatment plan update was completed on September 29, 2022, and the next treatment plan update was due no later than October 29, 2022; however, the update was not completed until December 1, 2022.
Client # 6 was admitted on November 14, 2022 and was active at the time of the inspection. A treatment plan update was completed on February 16, 2023, and the next treatment plan update was due no later than March 16, 2023; however, the update was not completed until March 27, 2023.
Client # 7 was admitted on February 23, 2023 and was active at the time of the inspection. A treatment plan update was completed on March 21, 2023, and the next treatment plan update was due no later than April 21, 2023; however, the update was not completed until April 29, 2023.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
As of July 6 2023 , the Program Director will begin conducting bi-weekly supervision with the clinical staff focusing on treatment planning. Biweekly supervisions will heavily focus on improving the treatment plan process between staff and clients. Furthermore, the Program Director will ensure that treatment plans are collaborative, personalized and mutually agreed upon. The Program Director along with the Compliance Team will monitor that treatment plans are updated every 30 days at a minimum and are done in combination with individual counseling sessions. |
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 ensure that counseling services were provided according to the individual treatment and rehabilitation plans in two of six applicable records reviewed.
Client # 1 was admitted on July 11, 2022 and was discharged on November 20, 2022. The treatment plan completed on October 12, 2022, indicated that the client was to receive one individual session per week; however, the record contained no documentation of an individual session between October 21, 2022 and the date of discharge.
Client # 7 was admitted on February 23, 2023 and was active at the time of the inspection. The treatment plans completed on March 21, 2023, April 29, 2023, and May 15, 2023, indicated that the client was to receive one individual session per week; however, the record contained no documentation of individual sessions between April 11, 2023 and April 25, 2023, or between May 1, 2023 and May 26, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 7/6/23, the clinical team met with the Program Director and were advised weekly counseling sessions must be conducted with all clients assigned to their caseload. In addition, the Program Director will participate in weekly chart audits and use biweekly supervision as a tool to measure and ascertain if counseling sessions are being conducted as mandated by treatment regulations. |
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 a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include case consultation information quarterly, per facility policy, in three of seven records reviewed.
Client # 2 was admitted on November 11, 2022 and was discharged on February 28, 2023. There was no documentation of case consultation information in the record.
Client # 3 was admitted on July 25, 2022 and was discharged on April 5, 2023. The only documentation of case consultation information occurred on August 10, 2022.
Client # 6 was admitted on November 14, 2022 and was active at the time of the inspection. There was no documentation of case consultation information in the record.
This is a repeat citation from the June 23, 2022 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning 7/6/23, the Program Director will conduct weekly chart audits and the Quality Assurance Department will conduct quarterly clinical chart audits focusing on the case consultation process. Chart audits will focus on ensuring case consults are completed at a minimum of every 30 days. The Program Director will ensure that all staff is trained on how to complete case consults in accordance with DDAP requirements and agency protocol by 7/25/23. All active clients who have not engaged in the case consult process will be provided with case consults by 8/1/23. |
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 ensure a complete client record included information relative to the client's involvement with the project, to include an aftercare plan, in one of two applicable records reviewed.
Client # 2 was admitted on November 11, 2022 and was discharged on February 28, 2023. There was no documentation of an aftercare plan in the record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 7/6/23 the Program Director along with Regional Director will monitor that aftercare plans are completed for all clients post transitioning or discharging from treatment. Program Director will conduct quarterly trainings to ensure that all staff in properly trained on the aftercare discharging process. Program Director will ensure All aftercare plans shall be person-centered and time-specific, outlining ongoing care that will be administered upon discharge. Aftercare will include but not be limited to the enrolling 12-step meetings, outpatient care, counseling, and a sober living facility. |
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 ensure a complete client record included information relative to the client's involvement with the project, to include a discharge summary, in two of four applicable records reviewed.
Client # 1 was admitted on July 11, 2022 and was discharged on November 20, 2022. There was no documentation of a discharge summary in the record.
Client # 2 was admitted on November 11, 2022 and was discharged on February 28, 2023. There was no documentation of a discharge summary in the record.
This is a repeat citation from the June 23, 2022 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 7/6/23 Program Director will
monitor all client charts for appropriate discharge documentation practices. Any staff that fails to have the required and approved documentation summmaries will meet with Program Director for a discharge process training.
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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 ensure a complete client record included information relative to the client's involvement with the project, to include follow-up information, in three of three applicable records reviewed.
Client # 1 was admitted on July 11, 2022 and was discharged on November 20, 2022. There was no documentation of follow-up information in the record.
Client # 2 was admitted on November 11, 2022 and was discharged on February 28, 2023. There was no documentation of follow-up information in the record.
Client # 4 was admitted on September 23, 2022 and was discharged on January 11, 2023. There was no documentation of follow-up information in the record.
This is a repeat citation from the June 23, 2022 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 7/6/23 the Program Director will conduct weekly chart audits related to the discharge and post treatment follow-up process. In addition, by 8/1/23 all staff will be trained on how to complete client follow-ups post the discharge process. The Program Director along Quality Assurance Department will conduct quarterly chart audits how aftercare plans are followed after the discharge process. Furthermore, Program Director will also utilize monthly supervisions to ensure all client charts contain pertinent information of the client involvement with the program and the client's status/wellbeing post treatment. |
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 obtaining client signed consent to release information forms prior to disclosures of information was submitted and approved by the Department for the June 23, 2022, June 2, 2021, and September 24, 2020, annual licensing inspections. Obtaining client signed consent to release information forms prior to disclosing information was again found to be a deficiency in the June 2, 2023, licensing inspection.
A plan of correction for calling client emergency contacts within 12 hours of an Against Staff Advice discharge was submitted and approved by the Department for the June 23, 2022, annual licensing inspection. Contacting emergency contacts was again found to be a deficiency in the June 2, 2023, licensing inspection.
A plan of correction for including case consultation information quarterly in the client record was submitted and approved by the Department for the June 23, 2022, annual licensing inspection. Completing case consultation information in the client record was again found to be a deficiency in the June 2, 2023, licensing inspection.
A plan of correction for including a discharge summary in the client record was submitted and approved by the Department for the June 23, 2022, annual licensing inspection. Completing a discharge summary was again found to be a deficiency in the June 2, 2023, licensing inspection.
A plan of correction for including follow-up information in the client record was submitted and approved by the Department for the June 23, 2022, annual licensing inspection. Completing follow-up information was again found to be a deficiency in the June 2, 2023, licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 7/6/23, The Program Director will be responsible for the implementation and compliance of all plans of correction. The Program Director will collect data from past inspections to determine how to avoid repeated citations and the best procedures for implementing new POC. It will be the responsible of the Program Director and the Division to ensure that future violations are not incurred in this area and that POC are put in place. The Division Director will also ensure POC are followed by meeting with Program Director to audit past and present POC procedures. The Compliance Quality Team will audit the program every quarter to make sure that the program remains in compliance. All data gathered from the monthly and quarterly audits will be recorded. These methods will focus on the proper protocol for completing client consents and releases, other relevant documentation, and POC. |