INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 28, 2021 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. 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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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of seven client records, the facility failed to document treatment plan updates within the regulatory timeframe in four client records reviewed.
Client #2 was admitted on May 4, 2020 and was still active at the time of the inspection. A treatment plan update was completed on December 17, 2020 and the next update was due no later than February 17, 2021; however, there was no update completed until March 12, 2021.
Client #4 was admitted on March 17, 2020 and was still active at the time of the inspection. A treatment plan update was completed on July 28, 2020and the next update was due no later than September 28th, 2020; however, there was no update completed until November 3, 2020.
Client #5 was admitted on November 16, 2019 and was discharged on June 4, 2020. A treatment plan update was completed on November 20, 2019 and the next update was due no later than January 20, 2020; however, there was no update completed until March 3, 2020.
Client #7 was admitted on February 18, 2020 and was discharged on December 1, 2020. A treatment plan update was completed on July 20, 2020 and the next update was due no later than September 20, 2020; however, there was no update completed until October 9, 2020.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
An all staff in service meeting will be held on May 21, 2021 to address clinical staff on treatment management procedures specific to the treatment plan update process. All staff will be directed to update treatment plans every 60 days or sooner. Should the client fail to attend the scheduled session to develop treatment plans as due, clinical staff will proceed and document that the plan will be reviewed with the client during the next attended session. The Program Director will review treatment plans for compliancy during the CQI process monthly. Clinical staff will be monitored monthly in regular supervisory sessions. |
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.
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Observations
Based on a review of three applicable client records, the facility failed to document a discharge summary in one client record reviewed.
Client #6 was admitted on January 12, 2021 and discharged on March 19, 2021.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
An all staff meeting will be held on May 21, 2021 to address clinical staff on treatment management procedures specific to continuing care/transition/discharge plan summaries. Clinical staff will be reminded that discharge documentation is due in the client chart within 7 days of discharge. The Program Director will review for compliance during the monthly internal CQI process. Clinical staff will be monitored monthly in regular supervisory sessions. Additionally, the Regional Quality Assurance department will conduct quarterly audits to ensure compliance; this audit will be documented in the quarterly CQI report. The compliance department will conduct annual reviews to ensure continued implementation of all action items on the corrective action plan. |
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.
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Observations
Based on a review of three applicable client records, the facility failed to document follow up information in all three records reviewed.
Client record #5 was admitted November 16, 2019 and discharged June 4, 2020.
Client record #6 was admitted on January 12, 2021 and discharged on March 19, 2021.
Client record #7 was admitted on February 18, 2020 and discharged on December 1, 2020.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
An all staff meeting will be held on May 21, 2021 to address clinical staff on treatment management procedures specific to assuring that follow up is to be completed for every type of discharge. Management staff reviewed the most efficient process and determined that the follow up will be completed by the assigned clinical staff and submitted as part of the discharge documentation process. The Program Director will review for compliance during the monthly internal CQI process. Clinical staff will be monitored monthly in regular supervisory sessions. Additionally, the Regional Quality Assurance department will conduct quarterly audits to ensure compliance; this audit will be documented in the quarterly CQI report. The compliance department will conduct annual reviews to ensure continued implementation of all action items on the corrective action plan. |