INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 25, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gaudenzia West Shore 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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709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the specific information to be disclosed in one out of seven records reviewed.
Client #6 was admitted on June 26, 2024 and discharged on January 13, 2025. The record contained one informed and voluntary consent to release information to an attorney and one informed and voluntary consent to release information to the funding source signed by the client on June 26, 2024, that did not document the specific information to be disclosed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On April 23rd, 2025, the Clinical Supervisor will meet with counselor and review the elements of release of information. The review will include checking off what information will be disclosed.
Ongoing, during monthly chart audits, Clinical Supervisor will review the releases that are in the charts for accuracy. Any errors will be emailed to the counselor to correct during the next visit with the client. |
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 a review of records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the purpose of disclosure in one out of seven records reviewed.
Client #6 was admitted on June 26, 2024 and discharged on January 13, 2025. The record contained one informed and voluntary consent to release information to an attorney and one informed and voluntary consent to release information to the funding source signed by the client on June 26, 2024, that had no purpose of disclosure documented.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On April 23rd, 2025, the Clinical Supervisor will meet with counselor and review the elements of release of information. The review will include checking off purpose of disclosure.
Ongoing, during monthly chart audits, Clinical Supervisor will review the releases that are in the charts for accuracy. Any errors will be emailed to the counselor to correct during the next visit with the client. |
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 that a comprehensive treatment plan was developed with the client and within guidelines established by the facility's policy and procedures manual in three out of seven records reviewed. The facility ' s policy and procedures manual states that the comprehensive treatment plan is completed within thirty days of admission.
Client #1 was admitted on December 31, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was completed on January 29, 2025; however, there is no documentation that the comprehensive treatment plan was completed with the client.
Client #2 was admitted on January 13, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than February 13, 2025; however, it was not completed until March 13, 2025 and there is no documentation that the comprehensive treatment plan was completed with the client.
Client #7 was admitted on September 23, 2024 and discharged on December 11, 2024. A comprehensive treatment plan was due no later than October 23, 2024; however, there is no documentation that one was completed.
These findings were reviewed with facility staff during the licensing process.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On April 23rd, 2025, the Clinical Supervisor will meet with the counselor and review the policy of completing Comprehensive Treatment Plans within 30 days of admission. The counselor will be provided a workflow for each admission that will offer guidance to the completion of documentation within the expected time frames. This document includes completing a Comprehensive Treatment Plan within 30 days of admissions.
Ongoing, during weekly Clinical Meetings, the Clinical Supervisor will provide counselor with the Treatment Plan Analysis report. This report details each client's record and due dates of required Treatment Plans. The Clinical Supervisor will continue to monitor adherence during monthly chart audits.
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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 client records, the facility failed to provide a complete client record on an individual which includes information relative to the client's involvement with the project, including a discharge summary in two out of four applicable records. The facility's policy and procedure manual states that a discharge summary is completed within seven days of discharge.
Client #5 was admitted July 23, 2024 and discharged on October 20, 2024. A discharge summary was due no later than October 27, 2024; however, there is no documentation that one was completed.
Client #7 was admitted on September 23, 2024 and discharged on December 11, 2024. A discharge summary was due no later than December 18, 2024; however, there is no documentation that one was completed.
This is a repeat citation from the August 24, 2021, March 31, 2022, May 12, 2023 and May 22, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On April 23rd, 2025, the Clinical Supervisor will meet with the counselor and review the policy of completing a Discharge Summary within 7 days of discharge from the program.
Clinical supervisor will monitor adherence to completion of discharge summaries by auditing 10% of all closed charts for that month.
If any discharge summaries are missing, the supervisor will have the primary counselor complete it within 48 hours of notification. |
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 three applicable discharged records reviewed. The facility ' s policy and procedures manual states that a follow up is due within 30 days if the client does not have an aftercare appointment scheduled.
Client #5 was admitted on July 23, 2024 and discharged on October 20, 2024. A follow up contact was due no later than November 20, 2024; however, there is no documentation that one was completed.
This is a repeat citation from the March 31, 2022, May 12, 2023 and May 22, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During clinical meeting on April 23rd, 2025, Clinical Supervisor will advise clinical staff to block off time in their schedule each week to focus on completing discharge paperwork, which will include reviewing timelines of when a follow up contact note is due. It will be expected that during their blocked off time for discharge paperwork, completion of Follow Up contact form will occur.
Clinical supervisor will monitor adherence of the follow up contact note being completed by auditing 10% of all closed charts for that month.
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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 a discharge summary was submitted and approved by the Department for the August 24, 2021, March 31, 2022, May 12, 2023, and May 22, 2024 annual licensing inspection. Completing and documenting a discharge summary was again found to be a deficiency in the March 25, 2025, licensing inspection.
A plan of correction for completing and documenting a follow up was submitted and approved by the Department for the March 31, 2022, May 12, 2023, and May 22, 2024, annual licensing inspection. Completing and documenting a follow up was again found to be a deficiency in the March 25, 2025, licensing inspection.
This is a repeat citation from the March 22, 2024 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning April 23rd, 2025 and occurring on a monthly basis, the Division Director will participate in a scheduled Clinical Meeting for this location. The Division Director will review the current POCs that are in place with the staff and also review the chart audits for the current month. This will allow the Division Director to follow through on current POCs. Any deficiencies will be reviewed with Clinical Supervisor the same day of the meeting and follow up with documentation will be requested. This will continue throughout the year. |