INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 22, 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, Inc. West Chester 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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709.53(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 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 progress notes entered within seven days of the date of service, per the facility's policy, in four of seven applicable records reviewed.
Client #1 was admitted on January 9, 2025 and was a current client at the time of the inspection. The record contained individual counseling session progress notes for March 25, 2025 and April 2, 2025 that were not documented in the record until April 11, 2025.
Client #2 was admitted on February 5, 2025 and was a current client at the time of the inspection. The record contained individual counseling session progress notes for February 4, 2025, and February 11, 2025, that were not documented in the record until March 21, 2025. Additionally, the record contained individual counseling session progress notes that were for February 27, 2025, and March 27, 2025, that were not documented in the record until April 11, 2025.
Client #4 was admitted on July 23, 2024 and was discharged on August 18, 2024. The record contained an individual counseling session progress note for August 5, 2024, that was not documented in the record until August 14, 2024.
Client #5 was admitted on July 10, 2024 and was discharged on August 31, 2024. The record contained an individual counseling session progress note for July 30, 2024, that was not documented in the record until August 9, 2024.
This is a repeat citation from the April 26, 2024, annual licensing renewal inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
An In-Service Training will be conducted with the Clinical Staff of West Chester House on June 3, 2025, to review the agency's policy regarding Clinical Documentation timeframes and expectations. This in-service training will include, but will not be limited to, review of previously established plan of correction, steps towards progress to eliminate deficiency, areas needing improvement to ensure compliance, and completion of progress notes in accordance with the timeframes outlined in agency/regulation policies and standards.
The Clinical Supervisor will conduct biweekly chart reviews to ensure that progress notes are completed in accordance with the timeframes outlined in agency policies and applicable regulatory standards. Any identified deficiencies will be documented and addressed within 48 hours. During biweekly supervision, the Clinical Supervisor and Program Director will jointly review audit findings, with a focus on the timeliness and completeness of documentation. Additionally, the Program Director will conduct a monthly audit of clinical notes to further assess compliance with established documentation timelines.
Should any trends or patterns of late documentation emerge from either the biweekly or monthly reviews, the Program Director will address these issues directly with the employee. A progressive disciplinary process will be used not only to enforce compliance but also as a coaching tool to identify and resolve any barriers impacting the employee's ability to meet required timelines.
Ultimately, it is the responsibility of the Program Director to ensure full implementation of this workflow. This includes verifying that any deficiencies are properly addressed and that expectations regarding documentation timeliness are consistently upheld.
On a rotating basis, the Quality Assurance Department will also monitor Program's compliance with the abovementioned standard, which will be completed during their quantitative and qualitative chart audits. Any issues identified will be brought to the immediate attention of the Program Director and rectified within forty-eight (48) hours.
Party (ies) Responsible: Clinical Staff of West Chester House, Clinical Supervisor, Program Director, and Quality Assurance Department
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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 the review of client records and the project ' s policies and procedures, the project failed to document a complete client record on an individual that included case consultation notes in four of six applicable client records reviewed.
Client #4 was admitted on July 23, 2024 and was discharged on August 18, 2024. A case consultation note was not documented in the client record, per the projects policy which indicates that one case consultation note is to be documented per each treatment episode.
Client #5 was admitted on July 10, 2024 and was discharged on August 31, 2024. A case consultation note was not documented in the client record, per the projects policy which indicates that one case consultation note is to be documented per each treatment episode.
Client #6 was admitted on July 23, 2024 and was discharged on September 11, 2024. A case consultation note was not documented in the client record, per the projects policy which indicates that one case consultation note is to be documented per each treatment episode.
Client #7 was admitted on October 9, 2024 and was discharged on November 18, 2024. A case consultation note was not documented in the client record, per the projects policy which indicates that one case consultation note is to be documented per each treatment episode.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
An In-Service Training will be conducted with the Clinical Staff of West Chester House on June 3, 2025, to review the agency's policy regarding Clinical Documentation timeframes and expectations. This in-service training will include, but will not be limited to, the completion and documentation of case consultations notes in accordance with the timeframes outlined in agency/regulation policies and standards.
The Clinical Supervisor will conduct biweekly chart reviews to ensure that case consultation notes are completed in accordance with the timeframes outlined in agency policies and applicable regulatory standards. Any identified deficiencies will be documented and addressed within 48 hours. During biweekly supervision, the Clinical Supervisor and Program Director will jointly review audit findings, with a focus on the timeliness and completeness of case consultation documentation. Additionally, the Program Director will conduct a monthly audit of clinical notes to further assess compliance with established documentation submission and timelines.
Should any trends or patterns of late documentation emerge from either the biweekly or monthly reviews, the Program Director will address these issues directly with the employee. A progressive disciplinary process will be used not only to enforce compliance but also as a coaching tool to identify and resolve any barriers impacting the employee's ability to meet required timelines.
Ultimately, it is the responsibility of the Program Director to ensure full implementation of this workflow. This includes verifying that any deficiencies are properly addressed and that expectations regarding documentation timeliness are consistently upheld.
On a rotating basis, the Quality Assurance Department will also monitor Program's compliance with the abovementioned standard, which will be completed during their quantitative and qualitative chart audits. Any issues identified will be brought to the immediate attention of the Program Director and rectified within forty-eight (48) hours.
Party (ies) Responsible: Clinical Staff of West Chester House, Clinical Supervisor, Program Director, and Quality Assurance Department
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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 the review of client records and the project ' s policies and procedures, the project failed to document a complete client record on an individual that included a discharge summary within seven days of discharge, in three of four applicable client records reviewed.
Client #4 was admitted on July 23, 2024 and was discharged on August 18, 2024. A completed discharge summary was not documented in the client record at the time of the inspection.
Client #5 was admitted on July 10, 2024 and was discharged on August 31, 2024. A discharge summary was not documented in the client record at the time of the inspection.
Client #7 was admitted on October 9, 2024 and was discharged on November 18, 2024. A discharge summary was not documented in the client record at the time of the inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
An In-Service Training will be conducted with the Clinical Staff of West Chester House on June 17, 2025, to review the agency's policy regarding Clinical Documentation timeframes and expectations. This in-service training will include, but will not be limited to, the completion and documentation of discharge summaries in accordance with the timeframes outlined in agency/regulation policies and standards.
The Clinical Supervisor will conduct biweekly chart reviews to ensure that discharge summaries are completed in accordance with the timeframes outlined in agency policies and applicable regulatory standards. Any identified deficiencies will be documented and addressed within 48 hours. During biweekly supervision, the Clinical Supervisor and Program Director will jointly review audit findings, with a focus on the timeliness and completeness of discharge summaries. Additionally, the Program Director will conduct a monthly audit of clinical notes to further assess compliance with established documentation submission and timelines.
Should any trends or patterns of late documentation emerge from either the biweekly or monthly reviews, the Program Director will address these issues directly with the employee. A progressive disciplinary process will be used not only to enforce compliance but also as a coaching tool to identify and resolve any barriers impacting the employee's ability to meet required timelines.
Ultimately, it is the responsibility of the Program Director to ensure full implementation of this workflow. This includes verifying that any deficiencies are properly addressed and that expectations regarding documentation timeliness are consistently upheld.
Finally, Regional Quality Assurance Staff complete qualitative and quantitative charts reviews on a quarterly basis. A plan of correction/completion is outlined for all identified deficiencies.
Party (ies) Responsible: Clinical Staff of West Chester House, Clinical Supervisor, Program Director, and Quality Assurance Department
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709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of seven client records, the facility failed to ensure that all work done by clients at the project is an integral part of their treatment and rehabilitation plan in all seven records reviewed.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
An In-Service Training will be conducted with the Clinical Staff of West Chester House on June 17, 2025, to review the agency's policy regarding Clinical Documentation timeframes and expectations. In addition to the agency's policy, this in-service training will include regulatory expectations regarding work as a component of an individual's treatment, which includes, not being limited to ensuring that work done by an individual within the program is integrated within his/her treatment plans.
The Clinical Supervisor will review treatment plans on a weekly basis to ensure that work as treatment is appropriately integrated in an individual's treatment plan in accordance with the timeframes outlined in agency policies and applicable regulatory standards. Any identified deficiencies will be documented and addressed within 48 hours. Additionally, the Program Director will conduct a monthly audit of treatment plans to further assess compliance with established regulatory standards.
Should any trends or patterns of late documentation emerge from either the biweekly or monthly reviews, the Program Director will address these issues directly with the employee. A progressive disciplinary process will be used not only to enforce compliance but also as a coaching tool to identify and resolve any barriers impacting the employee's ability to meet required timelines.
Ultimately, it is the responsibility of the Program Director to ensure full implementation of this workflow. This includes verifying that any deficiencies are properly addressed and that expectations regarding documentation timeliness are consistently upheld.
Finally, Regional Quality Assurance Staff complete qualitative and quantitative charts reviews on a quarterly basis. A plan of correction/completion is outlined for all identified deficiencies.
Party (ies) Responsible: Clinical Staff of West Chester House, Clinical Supervisor, Program Director, and Quality Assurance Department
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