INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 19, 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. 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) (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 client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients in five of seven client records reviewed. The policy states that treatment plan updates would be completed every thirty days for the intensive outpatient program.Client # 3 was admitted to the intensive outpatient level of care on June 16, 2023 and was discharged on March 29, 2024. The individual treatment and rehabilitation plan was completed on July 13, 2023, and the treatment plan update was due no later than August 13, 2023; however, it was not completed until August 23, 2023. Another treatment plan update was completed on November 30, 2023, and the next treatment plan update was due to be completed by December 30, 2023; however, the update was not completed until January 22, 2024. Client # 4 was admitted to the intensive outpatient level of care on October 24, 2022 and transferred to the outpatient level of care on October 13, 2023. A treatment plan update was completed on May 26, 2023, and the next treatment plan update was due no later than June 26, 2023; however, the treatment plan update was not completed until July 31, 2023. Another treatment plan update was completed on August 25, 2023, and the next treatment plan update was due to be completed by September 25, 2023; however, the update was not completed until October 13, 2023.Client # 5 was admitted to the intensive outpatient level of care on September 26, 2023 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on October 25, 2023, and the treatment plan update was due no later than November 25, 2023; however, it was not completed until December 6, 2023. The next treatment plan update was due to be completed by January 6, 2024; however, the treatment plan update was not completed until January 16, 2024. Client # 6 was admitted to the intensive outpatient level of care on September 12, 2023 and was transferred to the outpatient level of care on February 5, 2024. A treatment plan update was completed on November 14, 2023, and the next treatment plan update was due no later than December 14, 2023; however, the treatment plan update was not completed until January 11, 2024. Client # 7 was admitted to the intensive outpatient level of care on October 18, 2023 and was active at the time of the inspection. A treatment plan update was completed on December 13, 2023, and the next treatment plan update was due no later than January 13, 2024; however, the treatment plan update was not completed until February 15, 2024. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will hold an in-service training with the clinical team to review the requirements regarding Tx plan update time frames per our workflow, and time management skills no later than 6/1/2024.
The Program Director will complete monthly chart audits to include a review of Tx plan updates.
Division Director will complete bi-monthly audits.
The CQI Manager will conduct charts audits twice annually and review open plans of correction at each review.
Any issues noted will be brought to the immediate attention of the clinician responsible, to be corrected within 48 hours.
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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 five 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 as the Project Director on September 9, 2019 and is current in that position. The annual written staff performance evaluation was due to be reviewed and signed by the employee by February 1, 2024, however, it was not signed by the employee until February 28, 2024.Employee # 2 has been in the position of Facility Director since July 22, 2019. The annual written staff performance evaluation was due to be reviewed and signed by the employee by February 1, 2024, however, it was not signed by the employee as of the date of the inspection. The findings were reviewed with 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 Corporate Outpatient Directors will ensure that this process is completed for all Outpatient Division Directors.
The Division Directors will complete Annual Performance Evaluations for each of 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.
2/1/25
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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 to release information form from the client for the disclosure of information contained in two records reviewed. Client # 3 was admitted on June 16, 2023 and was discharged on March 29, 2024. The record did not contain an informed and voluntary consent form to the funding source; however, there was evidence of billing. Client # 4 was admitted on October 24, 2022 and was discharged on January 4, 2024. The record contained documentation of a disclosure of information to a probation officer on January 3, 2024; however, there was no client signed consent to release information form to the probation officer. This is a repeat citation from the May 22, 2023 annual licensing renewal inspection.These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Program Director will inform staff that all release for funding and external monitoring entities must be completed at time of intake during a clinical staff meeting by 5/24/24.
The Program Director will monitor the facility client census monthly and highlight any clients that have been in the program for a year that will require new releases and notify clinical team.
The Program Director will complete monthly chart audits to include a review of release of information.
Division Director will complete bi-monthly chart audits.
The CQI Manager will conduct charts audits twice annually and review open plans of correction at each review.
Any issues noted will be brought to the immediate attention of the clinician responsible, to be corrected within 48 hours
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709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to document that the client was notified, in writing, of the reason for the facility's decision to involuntarily terminate the client's treatment at the project in one applicable record reviewed.Client # 4 was admitted on October 24, 2022 and was involuntarily discharged on January 4, 2024. The record did not contain documentation that the client was notified, in writing, of the facility's reason to involuntarily terminate.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will hold an in-service training with clinical staff that includes documentation of reason for discharge and date of discharge for any treatment termination by 6/1/24.
The Program Director is involved in all treatment termination decisions and will monitor charts to ensure documentation of reasons and date of discharge are completed.
The Program Director will complete monthly chart audits to include a review of termination notice and required documentation.
Division Director will complete bi-monthly audits.
The CQI Manager will conduct charts audits twice annually and review open plans of correction at each review.
Any issues noted will be brought to the immediate attention of the clinician responsible, to be corrected within 48 hours.
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709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on the review of the unusual incident logbook, the project failed to file a written unusual incident report with the Department within three business days following an unusual incident involving the presence of police, fire, or ambulance personnel.There was documentation of the presence of ambulance and police personnel on November 21, 2023; however, there was no documentation that a written unusual incident report was ever filed with the Department.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Program Director will complete all required incident reports within 24 hours of incident.
The Program Director will print out all incident reports to maintain on site.
Division Director will follow up on incident reports monthly to ensure all appropriate entries are notified as required.
Incident on 11/21/23 was submitted to DDAP 5/10/24. Event number 1005913.
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709.92(c) LICENSURE Treatment and rehabilitation services
709.92. 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 four of seven records reviewed.Client # 2 was admitted on July 31, 2023 and was discharged on December 15, 2023. The treatment plan completed on October 27, 2023, indicated that the client was to receive one individual session per week and three groups per week; however, the record did not contain documentation of any individual or groups sessions between December 1, 2023 and the date of the discharge.Client # 3 was admitted on June 16, 2023 and was discharged on March 29, 2024. The treatment plans completed on November 30, 2023, and January 22, 2024, indicated that the client was to receive two individual sessions per month; however, the record did not contain documentation of any individual sessions during the month of January 2024.Client # 4 was admitted on October 24, 2022 and was discharged on January 4, 2024. The treatment plan completed on October 13, 2023, indicated that the client was to receive two individual sessions per month; however, there was only one documented individual session during the month of November 2023.Client # 6 was admitted on September 12, 2023 and was active at the time of the inspection. The treatment plans completed on January 11, 2024, and February 5, 2024, indicated that the client was to receive two individual sessions per month; however, there was only one documented individual session during the month of February 2024.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will run a notes audit report in the Company EHR bi-weekly to ensure that all notes are completed on time.
The Program Director will hold an in-service training with the clinical staff on documenting services and missed visits in the EHR by 6/1/24.
The Program Director will complete monthly chart audits to include a review of client record of service.
Division Director will complete bi-monthly audits.
The CQI Manager will conduct charts audits twice annually and review open plans of correction at each review.
Any issues noted will be brought to the immediate attention of the clinician responsible, to be corrected within 48 hours.
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709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on a review of client records and the facility policies and procedures, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include progress notes completed immediately after therapy sessions, in five of seven records reviewed. Client # 2 was admitted on July 31, 2023 and was discharged on December 15, 2023. The record contained progress notes for individual sessions occurring on November 3, 2023 and November 17, 2023, that were completed on November 8, 2023 and November 26, 2023, respectively.Client # 3 was admitted on June 16, 2023 and was discharged on March 29, 2024. The record contained a progress note for an individual session occurring on September 7, 2023, that was not completed until October 2, 2023. Additionally, the record contained a progress note for an individual session occurring on February 1, 2024, that was not completed until February 11, 2024.Client # 4 was admitted on October 24, 2022 and was discharged on January 4, 2024. The record contained a progress note for an individual session occurring on September 8, 2023, that was not completed until October 2, 2023. Additionally, the record contained a progress note for a group counseling session occurring on September 18, 2023, that was not completed until September 24, 2023.Client # 5 was admitted on September 26, 2023 and was active at the time of the inspection. The record contained progress notes for individual sessions occurring on October 4, 2023, October 25, 2023, and November 15, 2023, that were not completed until November 5, 2023, November 1, 2023, and November 26, 2023, respectively.Client # 6 was admitted on September 12, 2023 and was active at the time of the inspection. The record contained a progress note for an individual session occurring on November 14, 2023, that was not completed until November 26, 2023.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will address timely documentation with staff responsible during individual supervision. This will be documented in a supervision note no later than 5/24/24.
The Program Director will monitor the schedule calendar in the company EHR weekly to identify any missing notes.
The Program Director will run a notes audit report bi-weekly to monitor note completion.
Division Director will complete bi-monthly audits.
The CQI Manager will conduct charts audits twice annually and review open plans of correction at each review.
Any issues noted will be brought to the immediate attention of the clinician responsible, to be corrected within 48 hours.
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709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of seven client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include case consultation notes quarterly, per the facility's policy, in six of seven applicable records reviewed. Client # 1 was admitted on June 14, 2023 and was discharged on October 25, 2023. The case consultation note was due to be completed by September 14, 2023; however, it was not completed until October 4, 2023.Client # 2 was admitted on July 31, 2023 and was discharged on December 15, 2023. The client record did not contain documentation of case consultation notes.Client # 3 was admitted on June 16, 2023 and was discharged on March 29, 2024. The first case consultation note was due to be completed by September 16, 2023; however, it was not completed until October 5, 2023.Client # 4 was admitted on October 24, 2022 and was discharged on January 4, 2024. The client record did not contain documentation of case consultation notes.Client # 5 was admitted on September 26, 2023 and was active at the time of the inspection. The first case consultation note was due to be completed by December 26, 2023; however, it was not completed until January 31, 2024.Client # 6 was admitted on September 12, 2023 and was active at the time of the inspection. The client record did not contain documentation of case consultation notes.This is a repeat citation from the May 22, 2023 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will run a clinical forms audit report monthly that will show Case Consultation's due and completed and review with clinical staff.
The Program Director will complete monthly chart audits to include a review of Case Consults.
Division Director will complete bi-monthly audits.
The CQI Manager will conduct charts audits twice annually and review open plans of correction at each review.
Any issues noted will be brought to the immediate attention of the clinician responsible, to be corrected within 48 hours.
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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 client records and the facility ' s policy and procedure manual, 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. The policy states that the follow-up note is due to be completed within 30 days of the client ' s discharge.Client # 1 was admitted on June 14, 2023 and was discharged on October 25, 2023. The follow-up note was not completed until March 8, 2024.Client # 2 was admitted on July 31, 2023 and was discharged on December 15, 2023. The follow-up note was not completed until March 25, 2024.Client # 4 was admitted on October 24, 2022 and was discharged on January 4, 2024. The follow-up note was not completed until March 25, 2024.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will run a detail of discharge report monthly that highlights when Follow-ups are completed and provide to staff.
Moving forward, the Division Director and Program Director will adjust internal procedures for Follow-up completion. The Administrative Coordinator and CRS will be trained in completing Follow ups by 6/1/24.
The Program Director will monitor the Detail of discharge report monthly to ensure that follow ups are being completed.
Division Director will complete bi-monthly audits.
The CQI Manager will conduct charts audits twice annually and review open plans of correction at each review.
Any issues noted will be brought to the immediate attention of the clinician responsible, to be corrected within 48 hours.
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