INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 17, 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 Together 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on one of one applicable employee personnel record reviewed, the facility failed to provide documentation of at least two years experience or the completion of a core curriculum in clinical supervision for employee # 3.
Employee # 3 was hired as a clinical supervisor on May 19, 2023, and was still in this position at the time of the inspection. Based on employee # 3's resume and personnel record, there was no documentation of at least two years experience or the completion of a core curriculum in clinical supervision.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The current Clinical Supervisor completed the pre test for the DDAP Clinical Supervisory Training.
The Clinical Supervisor is scheduled to attend the 5 day training in July 2024.
The Program Director will ensure the Clinical Supervisor completes the training as scheduled.
The Program Director will complete a review of all employee training files on an at least quarterly basis to identify any upcoming training due dates and ensure that staff complete such trainings before the deadlines.
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705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. There were cameras in group rooms.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Gaudenzia has been granted a DDAP exception waiver to 705.4 (3) allowing video-only recording strictly for safety and security purposes in the common areas of the program, including areas which may be used for group sessions. This exception waiver was granted as of 6/18/24.
Gaudenzia is adding language to our consent forms to obtain informed consent from all clients to allow video-only recording strictly for safety and security purposes in the common areas of the program, including areas which may be used for group sessions. This language will be added to the consent forms no later than 6/30/24 and will then be reviewed and signed by all current clients prior to their next counseling session.
In the interim, the program will disable any camera which is positioned in such a way as to capture video of any counseling session. These cameras will be enabled once all clients have signed the consents, no later than 7/12/24.
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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 two of two applicable employee personal records reviewed, the facility failed to provide documentation of an annual written individual staff performance evaluations reviewed and signed by the employee completed by February 1, 2024, per policy.
Employee # 1 was hired as a project director on September 9, 2019. An annual performance evaluation was due no later than February 1, 2024; however, the annual performance evaluation was not documented until February 28, 2024.
Employee # 4 was hired at the facility on November 14, 2022, and promoted to the position of counselor on January 20, 2023. An annual performance evaluation was due no later than February 1, 2024; however, the annual performance evaluation was not documented until April 2024.
These 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 Deputy Directors will ensure that this process is completed for all 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.
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709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on a review of the facility policy and procedure manual, the drug storage area and medications shall be inspected by an assigned nurse or designated trained staff member at least quarterly. The Medication and Drug Storage Inspection form shall be completed quarterly by the individual conducting the inspection and by the nurse manager or program director who accompanies him/her during the inspection. The facility did not document inspections of the drug area and medications at least quarterly during this review period.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will complete quarterly inspections of the medication area with the nurse on duty and document on The Medication and Drug Storage Inspection form with the first occurring by 7/1/24. This form will be kept in a binder in the medical office. The Quality Assurance Department will conduct semi-annual audits to include reviewing the binder to ensure the quarterly audits are completed and documented appropriately.
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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 one of one applicable client record reviewed, the facility failed to provide documentation of the project notifying the client, in writing, of a decision to involuntarily terminate the client's treatment.
Client # 7 was admitted on December 20, 2023, and discharged on April 11, 2024. There was no documentation in the client record notifying the client in writing of termination from the project.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the June 21, 2023 and June 16, 2022 annual licensing inspections.
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Plan of Correction
Clinical Supervisor will facilitate a training by July 1, 2024 with the clinical staff regarding notifying the client in writing utilizing the Treatment Termination Notice of an involuntary termination.
The clinical supervisor will review during chart audits to ensure that this form is completed as indicated.
The Quality Assurance Manager will review during Semi Annual audits to ensure this form is completed prior to termination of services.
Any issues noted will be addressed with the clinician in a documented supervision session and corrected within 24 hours.
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709.34 (c) (1) 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:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on a review of unusual incidents, the facility failed to report to the Department within 3 business days an unusual incident involving physical or sexual assault by staff or a client. A report was made on April 20, 2024; however, was not reported to the Department.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon approving an internal incident report, the Program Director, with the assistance of the Administrator will ensure that required incident reports are submitted to DDAP within three business days utilizing the DDAP ERS portal.
The Program Director will review incident reporting requirements with all staff at the June 20, 2024 all staff meeting.
CQI will review incident reports for timely submission during semi-annual audits.
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709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on three of seven applicable client records reviewed, the facility failed to provide documentation of a physical examination within seven days in accordance with the facility policy and procedure manual.
Client # 2 was admitted on February 8, 2024, and was still active at the time of the inspection. There was no documentation of a physical examination.
Client # 6 was admitted on December 12, 2023, and was discharged March 13, 2024. There was no documentation of a physical examination.
Client # 7 was admitted on December 20, 2023, and was discharged April 11, 2024. There was no documentation of a physical examination.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will audit the chart upon admission and communicate with the medical department the need for a physical within 7 days.
The Clinical supervisor will audit a sample of charts weekly to ensure the physical is completed. If one is missing, he will contact the medical department to schedule a physical.
The Clinical Supervisor will run the Medical Audit report one time weekly to ensure the physical has been completed.
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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 three of seven applicable client records reviewed, the facility failed to provide a psychosocial evaluation in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicated a psychosocial evaluation be completed within five days of admission and include a narrative psychosocial assessment. The assessment shall include a client description, the referral source, presenting and underlying problems, treatment issues, client coping mechanisms, factors contributing to addiction, client strengths and weaknesses, client motivation, support system, client response during the intake, receptivity to treatment and client attitude, ability to participate in treatment, client motivation, support systems, treatment recommendations, diagnosis, and prognosis. Emphasis is placed on the documentation of the client ' s strengths, abilities, and preferences (SNAP).
Client # 2 was admitted on February 8, 2024, and was still active at the time of the inspection. The biopsychosocial evaluation did not include the counselor narrative psychosocial assessment required by the facility policy and procedure manual.
Client # 3 was admitted on April 29, 2024, and was still active at the time of the inspection. The biopsychosocial evaluation did not include the counselor narrative psychosocial assessment required by the facility policy and procedure manual.
Client # 5 was admitted on January 9, 2024, and was discharged February 8, 2024. The biopsychosocial evaluation did not include the counselor narrative psychosocial assessment required by the facility policy and procedure manual.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will train Clinical staff in how to complete narrative assessments using the interpretive summary form in our EHR by June 20, 2024.
The Clinical Supervisor will ensure narrative assessments are included prior to the approval of Biopsychosocial forms.
CQI will also review documents for narratives in their semi-annual audits.
Any issues noted will be addressed with the clinician in a documented supervision session and corrected within 24 hours.
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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 four of four applicable client records reviewed, the facility failed to review and update the treatment and rehabilitation plans at least every thirty days.
Client # 1 was admitted on March 19, 2024, and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on March 30, 2024. A treatment and rehabilitation plan update was due no later than April 30, 2024; however, it was not completed until May 14, 2024.
Client # 2 was admitted on February 8, 2024, and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on March 21, 2024. A treatment and rehabilitation plan update was due no later than April 21, 2024; however, it was not completed until May 15, 2024.
Client # 6 was admitted on December 12, 2023, and was discharged on March 13, 2024. A treatment and rehabilitation plan was developed on January 10, 2024. A treatment and rehabilitation plan update was due no later than February 10, 2024; however, it was not completed until March 12, 2024.
Client # 7 was admitted on December 20, 2023, and was discharged on April 11, 2024. A treatment and rehabilitation plan was developed on February 29, 2024. A treatment and rehabilitation plan update was due no later than March 29, 2024; however, there was no treatment plan update documented.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the June 21, 2023 annual licensing inspection.
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Plan of Correction
The Clinical Supervisor will complete a training with the clinical staff regarding the timeframes for the development of the treatment plan utilizing the Workflow document.
Clinical Supervisor will complete random chart audits to ensure the treatment plans are completed in the time frames needed. If treatment plans are not completed in the timeframe needed, the clinical supervisor will review during individual supervision.
The Program Director will ensure treatment plans are completed in the time frames needed through a review of monthly chart audits.
Any issues noted will be addressed with the clinician in a documented supervision session and corrected within 24 hours.
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709.53(a)(5) LICENSURE Progress 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:
(5) Progress notes.
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Observations
Based on three of seven applicable client records reviewed, the facility failed to provide a complete progress note to reflect the clinician ' s assessment of the client ' s progress in treatment, per facility policy.
Client # 5 was admitted on January 9, 2024, and was discharged February 8, 2024. Group progress notes on February 6, 2024, did not include the clinician ' s assessment of the client ' s participation in the group.
Client # 6 was admitted on December 12, 2023, and was discharged on March 13, 2024. Group progress notes on March 13, 2024, did not include the clinician ' s assessment of the client ' s participation in the group.
Client # 7 was admitted on December 20, 2023, and was discharged on April 11, 2024. Group progress notes on March 10, 2024, did not include the clinician ' s assessment of the client ' s participation in the group.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will provide training on completing group session assessments in the notes with the clinical team by June 20 2024.
The Clinical Supervisor will ensure assessments are completed on group notes through a review of minimally two group notes per clinician each week.
The Program Director will ensure assessments are completed on group notes through a review of two group notes per clinician bi-monthly.
CQI will ensure assessments are completed on group notes through a quarterly review.
Any issues noted will be addressed with the clinician in a documented supervision session and corrected within 24 hours.
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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 one of three applicable client records reviewed, the facility failed to provide a discharge summary in accordance with the facility policy and procedure manual. The policy and procedure manual indicates a discharge summary be completed within 7 days of discharge.
Client # 7 was admitted on December 20, 2023, and was discharged on April 11, 2024. The discharge summary was due to be completed no later than April 18, 2024, however, there was no discharge summary documented.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the June 21, 2023, June 16, 2022, and June 24, 2021 annual licensing inspections.
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Plan of Correction
The Clinical Supervisor will provide training to the clinical team on completing discharge summaries within established timeframes. This training will occur by June 20, 2024.
The Clinical Supervisor will review 2 discharge charts monthly to assist in ensuring summaries are completed.
CQI will ensure discharge summaries are being completed as part of semi-annual audit.
Any issues noted will be addressed with the clinician in a documented supervision session and corrected within 24 hours.
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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 two of three applicable client records reviewed, the facility failed to provide follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicated a follow-up is to occur within one week of referral or thirty days after discharge.
Client # 5 was admitted on January 9, 2024, and was discharged February 8, 2024. There was no follow-up information documented in the client record.
Client # 7 was admitted on December 20, 2023, and was discharged on April 11, 2024. There was no follow-up information documented in the client record.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the June 21, 2023, June 16, 2022 annual licensing inspections.
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Plan of Correction
The Program Director/Clinical Supervisor will review the requirements regarding completion of follow-up contact when a client is discharged during an all staff meeting by 7/1/24. This will include completing a follow up contact with the program the client was referred to within 7 days of the appointment or if the client was not referred to another program, within 30 days of discharge. This training will include review of the standard workflow and reference the specific form in our EHR.
In addition, the Program Director will monitor this area during monthly file audits and address discrepancies during staff supervision.
The Quality Assurance Department will conduct semi-annual audits to include reviewing documentation of follow up contacts as appropriate.
Any issues noted will be addressed with the clinician in a documented supervision session and corrected within 24 hours.
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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.
Plans of correction for completing follow up information were submitted and approved by the Department for the June 21, 2023, and June 16, 2022, licensing inspections. Follow up information was again found to be a deficiency in the May 17, 2024, licensing inspection.
Plans of correction for completing discharge summaries were submitted and approved by the Department for the June 21, 2023, June 16, 2022, and June 24, 2021 licensing inspections. Discharge summary information was again found to be a deficiency in the May 17, 2024, licensing inspection.
Plans of correction for completing termination notification were submitted and approved by the Department for the June 21, 2023, and June 16, 2022, licensing inspections. Termination notification was again found to be a deficiency in the May 17, 2024, licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will be ultimately 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 a new POC. It will be the responsibility of the Program Director and the Division to ensure that future violations are not incurred in this area and that POC's 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 Quality Assurance Team will audit the program semi annually to make sure that the program remains in compliance. All data gathered from the monthly and semiannual audits will be recorded. These methods will focus on the proper protocol for completing all relevant documentation.
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