INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 1, 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. 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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709.25 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.
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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.
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Plan of Correction
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.
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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 a review of seven client records, the facility failed to treatment and rehabilitation plans at least every 30 days in three records reviewed.
Client #4 was admitted on March 4, 2022 and was current at the time of the inspection. Client #4 had a treatment plan dated April 8, 2022, and the next update was due by May 8, 2022; however, one was not documented in the client record.
Client #5 was admitted on January 24, 2022 and was current at the time of the inspection. Client #5 had a treatment plan dated March 24, 2022, and the next update was due by April 24, 2022; however, one was not documented in the client record.
Client #7 was admitted on February 23, 2022 and was current at the time of the inspection. Client #7 had a treatment plan dated March 23, 2022, and the next update was due by April 23, 2022; however, the next update was not documented until June 1, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective June 6, 2022, client treatment plans will be reviewed and discussed,
including upcoming treatment plan reviews during monthly clinical meetings/supervisions. As of
June 18, 2022, clients #4, #5, and #7 treatment plans has been updated.
The Clinical Supervisor will review all active client treatment plans to ensure that plans are being updated according to regulatory guidelines.
The Program Director or designee, will run the clinical scorecard at least weekly from our electronic health records system to monitor treatment plan update completion per due dates. This information will be shared with clinical staff.
In addition, the Division Director will conduct monthly audits and the Quality Assurance Department will conduct quarterly reviews.
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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 a review of client records, 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 one of one applicable record reviewed.
Client #1 was admitted on April 8, 2022 and discharged on April 19, 2022.
These findings were reviewed with facility staff during the licensing process.
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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. As of June 27, 2022, client #1 follow-up note will be documented in her records.
Staff have been re-trained in an in-service on June 2, 2022 conducted by the Program Director regarding this regulation, and how to properly document follow-up in the record using our Follow-Up Contact form.
An internal tracking tool for each chart has been developed to help remind staff of upcoming documentation requirements. This includes follow-up post-discharge. The Program Director will send a reminder to clinicians at the beginning of each month noting which clients are due for follow-up. Clinical staff will send all treatment plans to Program Director for approval. Calendars are being utilized to keep close track of time-sensitive dates for each client. Upcoming follow-ups will be reviewed in weekly Clinical Staff meeting.
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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
The project failed to document, in the client's complete record, verification that any work done by the client at the project is an integral part of his/her treatment and rehabilitation plan in three of seven client records reviewed.
Client #4 was admitted on March 4, 2022 and was current at the time of the inspection.
Client #5 was admitted on January 24, 2022 and was current at the time of the inspection.
Client #7 was admitted on February 23, 2022 and was current at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff have been re-trained in an in-service on June 2, 2022 conducted by the Program Director regarding this regulation, and how to properly document this in the record. The Program Director reviewed the treatment plan form, and the specific areas designed to be used to indicate this. As of June 27, 2022, clients #4, #5, and #7 will be updated to include documentation of verification that work done is an integral part of her treatment and rehabilitation plan.
The Program Director will conduct monthly audits of a sample of charts in order to ensure that treatment plans properly document work as treatment.
The Division Director will conduct monthly audits of a sample of charts. Any missing documentation will be brought to the attention of the Program Director 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.
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