INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on January 21, 2025 through January 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 DRC, 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:
|
Plan of Correction
|
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.
|
Observations
Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in three of seven client records reviewed.
Client #1 was admitted on June 11, 2024, and was discharged on December 5, 2024. A release of information form for the funding source was not documented in the client record; however, the facility verified that billing had occurred.
Client #2 was admitted on March 14, 2024, and was discharged on August 1, 2024. A release of information form for the funding source was not documented in the client record; however, the facility verified that billing had occurred.
Client #3 was admitted on April 9, 2024, and was discharged on November 18, 2024. A release of information form for the funding source was not documented in the client record; however, the facility verified that billing had occurred.
This is a repeat citation from the November 28, 2023 annual licensing renewal inspection.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
This issue was resolved on 1/23/25 during a documented supervision session. All staff are now clear on the need for funding consent. Ongoing monthly chart audits will make this item a priority to ensure it has been fully resolved and applicable consents are signed for all current and incoming clients. Any issues noted in chart audits will be brought to the immediate attention of the clinician, documented in supervision, and corrected within 72hrs. Deputy Director will incorporate this item into monthly supervision to add an additional layer of oversight. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of client records and the project's policies and procedures, the project failed to document a psychosocial evaluation at admission, per facility policy, in five of seven client records reviewed.
Client #2 was admitted on March 14, 2024, and was discharged on August 1, 2024. The psychosocial evaluation was not documented in the client ' s record.
Client #4 was admitted on February 19, 2024, and was discharged on June 4, 2024. The psychosocial evaluation was not documented in the client ' s record.
Client #5 was admitted on January 18, 2024, and was an active client at the time of the inspection. The psychosocial evaluation was not documented in the client ' s record.
Client #6 was admitted on March 8, 2024, and was an active client at the time of the inspection. The psychosocial evaluation was not documented in the client ' s record.
Client #7 was admitted on March 18, 2024, and was an active client at the time of the inspection. The psychosocial evaluation was not documented in the client ' s record.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Staff training will occur no later than 2/28/25 to review workflow for completion of psychosocial evaluation, as well as outlining expectations from a qualitative perspective. Monthly chart audits will occur for 5 charts per counselor, verifying that psychosocial forms were completed and done in a qualitatively acceptable manner which provides thorough documentation. Any issues noted in chart audits will be brought to the immediate attention of the clinician, documented in supervision, and corrected within 72hrs. Completion of this item will be incorporated into monthly supervision between Program Director and Deputy Director. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
|
Observations
Based on a review of client records and the project's policies and procedures, the project failed to document a preliminary treatment plan during intake, per facility policy, in three of seven client records reviewed.
Client #2 was admitted on March 14, 2024, and was discharged on August 1, 2024. A preliminary treatment plan was not documented in the client record.
Client #5 was admitted on January 18, 2024, and was an active client at the time of the inspection. A preliminary treatment plan was not documented in the client record.
Client #6 was admitted on March 8, 2024, and was an active client at the time of the inspection. A preliminary treatment plan was not documented in the client record.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Staff have been trained in this area as of 2/6/25. An additional review of Assessment/Intake workflow will occur in order to develop a more efficient process to ensure preliminary treatment plan is completed for all admitted clients. This revised workflow will be completed and implemented no later than 2/28/25. As of 2/3/25, the program adjusted its process for screening and scheduling to more effectively leverage our Helpline which will prevent clients from being admitted prematurely, creating timing issues with required documentation. Review of preliminary treatment plans will be a priority in monthly chart audits and topic in monthly supervision between Program Director and Deputy Director. Any issues noted in chart audits will be brought to the immediate attention of the clinician, documented in supervision, and corrected within 72hrs. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
|
Observations
Based on a review of client records, the facility failed to document whether a client participated in the development of the individual treatment and rehabilitation plan in four of seven client records reviewed.
Client #2 was admitted on March 14, 2024, and was discharged on August 1, 2024. A comprehensive treatment plan completed on April 17, 2024, did not include documentation that the client participated in the development of the comprehensive treatment plan.
Client #3 was admitted on April 9, 2024, and was discharged on November 18, 2024. A comprehensive treatment plan completed on May 9, 2024, did not include documentation that the client participated in the development of the comprehensive treatment plan.
Client #4 was admitted on February 19, 2024, and was discharged on June 4, 2024. A comprehensive treatment plan was not documented in the client record.
Client #5 was admitted on January 18, 2024, and was an active client at the time of the inspection. A comprehensive treatment plan was not documented in the client record.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
As of 2/6/25, Staff have been trained in the development of treatment plans and the associated required timelines. Additional training and coaching support will occur to ensure that it is clearly documented that treatment plans have been developed with clients ensuring that treatment plans are signed, or that if a client misses the scheduled appointment when treatment plan was to be reviewed, it is clearly documented as being cause of delay for client review and signature. Review of preliminary treatment plans will be a priority in monthly chart audits and topic in monthly supervision between Program Director and Deputy Director. Any issues noted in chart audits will be brought to the immediate attention of the clinician, documented in supervision, and corrected within 72hrs. |
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.
|
Observations
Based on a review of client records, the project failed to ensure that counseling services are provided according to the individual treatment and rehabilitation plan in three of six applicable client records reviewed.
Client #1 was admitted on June 11, 2024, and was discharged on December 5, 2024. A comprehensive treatment and rehabilitation plan, documented in the client record on September 11, 2024, indicated that the client was to receive one individual counseling session per week; however, there was no individual counseling session documented in the client record for the weeks of September 22, 2024 through September 28, 2024, September 29, 2024 through October 5, 2024, October 13, 2024 through October 19, 2024, October 20, 2024 through October 26, 2024, November 3, 2024 through November 9, 2024, November 10, 2024 through November 16, 2024, November 17, 2024 through November 23, 2024 and November 24, 2024 through November 30, 2024.
Client #2 was admitted on March 14, 2024, and was discharged on August 1, 2024. A comprehensive treatment and rehabilitation plan, documented in the client record on March 15, 2024, indicated that the client was to receive one individual counseling session per week; however, there were no individual counseling sessions documented in the client record after the initial individual counseling session on March 14, 2024.
Client #3 was admitted on April 9, 2024, and was discharged on November 18, 2024. A comprehensive treatment and rehabilitation plan, documented in the client record on February 16, 2024, indicated that the client was to receive one individual counseling session per week; however, there was only one individual counseling session documented in the record for an individual counseling session that took place on July 24, 2024.
This is a repeat citation from the November 28, 2023 annual licensing renewal inspection.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Program staff will receive training on the completion of no-show notes and or independent notes documenting outreach efforts when a client cancels or re-schedules a session. Staff will document in a clear and timely manner when an appointment is missed to ensure that treatment attendance conforms with treatment plan or the reasons for deviation from the schedule are documented. This training will occur no later than 2/28/25. No show and Independent notes will be a priority of monthly chart audits and topic will be reviewed in monthly supervision between Program Director and Deputy Director. Any issues noted in chart audits will be brought to the immediate attention of the clinician, documented in supervision, and corrected within 72hrs. |
709.93(a)(10) 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:
(10) Discharge summary.
|
Observations
Based on the review client records, the project failed to document a complete client record on an individual that included a discharge summary in two of four applicable client records reviewed.
Client #2 was admitted on March 14, 2024, and was discharged on August 1, 2024. A discharge summary was not documented in the client record at the time of the licensing inspection.
Client #3 was admitted on April 9, 2024, and was discharged on November 18, 2024. A discharge summary was not documented in the client record at the time of the licensing inspection.
This is a repeat citation from the November 28, 2023 annual licensing renewal inspection.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Staff will receive additional training to review workflow related to discharge process as well as review the expected process for completion of discharge summary documentation. Training will occur no later than 2/28/25. Monthly chart audits will include at least 1 discharge chart to ensure that discharge process is being followed by counselors. Any issues noted in chart audits will be brought to the immediate attention of the clinician, documented in supervision, and corrected within 72hrs. |
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.
|
Observations
Based on the review of client records, the project failed to document a complete client record on an individual that included follow-up information in three of four applicable client records reviewed.
Client #1 was admitted on June 11, 2024, and was discharged on December 5, 2024. Follow-up information was not documented in the client record at the time of the inspection.
Client #3 was admitted on April 9, 2024, and was discharged on November 18, 2024. Follow-up information was not documented in the client record at the time of the inspection.
Client #4 was admitted on February 19, 2024, and was discharged on June 4, 2024. Follow-up information was not documented in the client record at the time of the inspection.
This is a repeat citation from the November 28, 2023 annual licensing renewal inspection.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
The workflow for completion of follow up form will be reviewed and adjusted to ensure standardization of process and more effective completion of this requirement. This revised workflow will be implemented no later than 2/28/25. Applicable training will be scheduled to assist staff members in completion of this process which will also occur no later than 2/28/25. Monthly chart audits will include at least 1 discharge chart to ensure that the follow up schedule is being followed by staff. Any issues noted in chart audits will be brought to the immediate attention of the clinician, documented in supervision, and corrected within 72hrs. |