INITIAL COMMENTS
|
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, Gaudenzia Inc. Fountain Springs 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:
|
Plan of Correction
|
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.
|
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.
|
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.
Target Date9/30/22
|
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.
|
Observations
Based on a review of client records on April 27, 2022 the facility failed to document treatment plan updates within the regulatory timeframe in three out of seven client records reviewed.
Client #2 was admitted on January 14, 2022 and was current at the time of the inspection. A treatment plan update was completed on February 18, 2022, with the next being due no later than March 18, 2022 but was but was not completed until March 22, 2022.
Client #3 was admitted on February 3, 2022 and was current at the time of the inspection. A treatment plan update was completed on February 8, 2022, with the next two being due no later than March 8, 2022 and April 8, 2022. However, they were not completed until March 10, 2022, and April 15, 2022.
Client #4 was admitted on February 7, 2022 and was still current at the time of the inspection. A treatment plan update was completed on February 11, 2022, and the next were due by March 11, 2022 and April 11, 2022. However, they were not documented at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Staff were re-trained in an in-service on 5/19/22 conducted by the Clinical Supervisor regarding this regulation, and how to properly document this in the record.
The Clinical Supervisor will send a reminder to clinicians at the beginning of each month noting which clients are due for Treatment Plan updates.
The Clinical Supervisor will conduct weekly audits of a sample of charts in order to ensure that timely treatment plan updates are completed for all charts. Any missing documentation will be brought to the attention of the clinician and completed within 48 hours.
The Acting Program Director will conduct monthly audits of a sample of charts in order to ensure that timely treatment plan updates are completed for all discharged charts. Any missing documentation will be brought to the attention of the Clinical Supervisor in order to follow up with the clinician in supervision and completed within 48 hours.
The Quality Assurance Department will conduct at least quarterly audits to include all Plans of Correction to ensure full implementation.
Completed 5/19/22
|
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.
|
Observations
Based on a review of seven client records on April 27, 2022, the project failed to have a complete client record on three of three applicable clients that included information relative to the client's involvement with the project, including follow-up information.
Client #5 was admitted on August 19, 2021 and was discharged on November 15, 2021. Client #5 did not have documentation of follow-up information in the client record.
Client #6 was admitted on September 10, 2021 and was discharged on November 4, 2021. Client #6 did not have documentation of follow-up information in the client record.
Client #7 was admitted on January 3, 2022 and was discharged on January 13, 2022. Client #7 did not have documentation of follow-up information in the client record.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
All clients will be contacted post-discharge and this contact (or attempt) will be documented in our electronic health record on the Follow Up Contact Note created for this purpose. This will occur within 7 days of the date of the referral appointment for completions, and within 30 days for all other discharges.
Staff were re-trained in an in-service conducted on 5/19/22 by the Clinical Supervisor regarding this regulation, and how to properly document this in the record.
The Clinical Supervisor will send a reminder to clinicians at the beginning of each month which clients are due for a follow-up call. The Clinical Supervisor will conduct weekly audits of a sample of charts in order to ensure that this is completed for all discharged charts. Any missing documentation will be brought to the attention of the clinician and completed within 48 hours.
The Acting Program Director will conduct monthly audits of a sample of charts in order to ensure that this is completed for all discharged charts. Any missing documentation will be brought to the attention of the Clinical Supervisor in order to follow up with the clinician in supervision and completed within 48 hours.
The Quality Assurance Department will conduct at least quarterly audits to include all Plans of Correction to ensure full implementation.
Completed 5/19/22
|