INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 27, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gaudeniza 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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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review fire drills from July 2021 through April 2022 the facility failed to conduct unannounced drills during the 2021 month of December. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Division Director reviewed with Administrative Assistant on 5/19/2022 during supervision the required the standard of conducting monthly unannounced drills.
Division Director will continue to monitor safety drills (including fire drills) with Administrative Assistant on a monthly basis, prior to each safety meeting committee meeting which is the 3rd Friday of each month. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review fire drills from July 2021 through April 2022 the facility failed to set off a fire alarm or smoke detector during each fire drill.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A letter has been mailed to DDAP on 5/19/2022 requesting an exception from having to set off a fire alarm or smoke detector during each fire drill due to the fact that the suite we occupy in the building at 201 Lincoln Way West, McConnellsburg is not set up with a fire alarm system, but rather a sprinkler system and individual smoke detectors in the suite.
The office will being using Liquid Smoke in June 2022, to set off a smoke detector in the office to alert staff/clients of a fire drill. The fire drill will be documented as per regulation and it will be unannounced on a monthly basis.
The office will use Liquid Smoke while a decision is being made on the exception letter and thereafter. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a review of administrative documents submitted, the project failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.The project's last annual financial audit was for the years ending June 30, 2020 and 2019. These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
The Annual Financial Audit for the most recent fiscal year (FY 2020 ? 2021) was not completed in a timely manner due to the delays on the part of the independent certified public accounting firm.
Among these delays were the application of new standards regarding the review of all leased properties (to include all real estate, business machines, and vehicles). This was a very laborious process that will not need to be repeated in the future.
Gaudenzia will obtain a completed financial audit from the independent certified public accounting firm on or before September 30th of 2022.
In order to help ensure that these delays do not occur in the future, the reorganized Fiscal department will begin preparation of all possible documents required for the audit as early as possible in the year.
Leadership in this department reviewed the regulations in DDAP 709.25 on 4/26/22 in order to ensure that all understand the importance of timely completion of the Financial Audit.
The Chief Financial Officer will oversee this process.
Completion date: 9/30/2022 |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of seven inpatient client records, the facility failed to provide a complete client record, which is to include an aftercare plan in one of the three applicable client records reviewed. Client #7 was admitted on June 29, 2021 and was discharged on February 22, 2022. There was not documentation of an aftercare plan being completed in the client record. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Division Director will review requirements and timeframe for a completed aftercare plan on May 20th, 2022 with the clinical team. The review will include the entire "bundle" of discharge documents for each client that must be completed at the time of discharge, regardless of discharge reason.
Ongoing, the Division Director will select both discharged and active charts to review for monthly chart audits to ensure that the "bundle"-Continuing Care/Transition Plan/Discharge Summary-is being started and completed as required.
If compliance continues to be a concern, Division Director will use individual supervision as a way to manage and increase the completion of these required documents.
Should the documents not be completed, Division Director will address during monthly individual supervision. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of seven inpatient client records, the facility failed to provide a complete client record, which is to include discharge summaries in one of the three applicable client records reviewed. Client #7 was admitted on June 29, 2021 and was discharged on February 22, 2022. There was not documentation of a discharge summary being completed in the client record. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Division Director will review requirements and timeframe for completed discharge summaries with the clinical team on May 20th, 2022.
During individual supervision on May 23rd, 2022 with primary counselor of Client #7, the Division Director will ask that the discharge summary be completed and submitted by 5/27/2022, although it will be late.
Ongoing, the Division Director will provide the list of Discharges weekly for the counselors during the clinical meeting and will follow up by going into the record to ensure the documents have been completed.
Should the documents not be completed, Division Director will address during monthly individual supervision.
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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 seven client records, the facility failed to document follow up information in two of three applicable client records reviewed. Client #5 was admitted on January 13, 2021 and was discharged on January 19, 2022. There was no documentation of follow up information being completed in the client record. Client #7 was admitted on June 29, 2021 and was discharged on February 22, 2022. There was no documentation of follow up information being completed in the client record. These findings were reviewed with facility staff during the licensing process.This is a repeat citation from an inspection conducted on May 26, 2021.
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Plan of Correction
Beginning May 20th, 2022 the Division Director will be providing a list of discharged clients from the past 2 weeks for each counselor.
The Division Director will provide the due date of each follow up based on the discharge reason to each counselor.
As required, the counselor will make the follow up call (according to due date) and document it in the EHR by completing the form, Follow Up Contact Note. This will assist the Division Director during monthly audits of both open and closed charts to ensure the follow up is being completed. |