D&A Facility Surveys

Pennsylvania Department of Drug & Alcohol Programs
Inspection Results

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GAUDENZIA MONTGOMERY COUNTY OUTPATIENT
166 WEST MAIN STREET
NORRISTOWN, PA 19401

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Survey conducted on 10/22/2020

INITIAL COMMENTS
Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection. The inspection will be divided into two parts. 1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist. 2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection. This report is a result of Part 2, an abbreviated on-site inspection, conducted on October 22, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1. Based on the findings of Part 2, an abbreviated on-site inspection, Gaudenzia Montgomery County Outpatient 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) (1) 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. The consent must be in writing and include, but not be limited to: (1) Name of the person, agency or organization to whom disclosure is made.
Observations The project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the name of the person, agency or organization to whom disclosure would be made to in two of seven client records reviewed. Client # 6 was admitted on February 28, 2020 and was discharged on September 2, 2020. A release of information form, signed and dated by the client on November 4, 2019, did not have the name of the person, agency or organization to whom the disclosure is made documented on the form. Client # 7 was admitted on March 4, 2020 and was current client at the time of the inspection. A release of information form, signed and dated by the client on March 4, 2020, did not have the name of the person, agency or organization to whom the disclosure is made documented on the form. These findings were reviewed with facility staff during the licensing process.	Plan of Correction All consents will be fully and completely filled out, to include the name of the person, agency or organization to whom disclosure is made. All clinical staff will be trained by the Facility Director in an in-service training on 11/12/2020 regarding these limits as well as the correct use of the release of information form in the electronic health record. The Clinical Supervisor will conduct at least weekly audits of charts in order to ensure compliance. The Quality Assurance department will conduct at least quarterly reviews of the program in order to ensure compliance. The findings of these audits will be reviewed in regular CQI meetings following the audits. The Compliance department will conduct at least annual reviews to ensure compliance with corrective action plan by 12/15/20.
709.28 (c) (2) 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. The consent must be in writing and include, but not be limited to: (2) Specific information disclosed.
Observations The project failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in one of seven client records reviewed. Client #4 was admitted on February 13, 2020 and was discharged on October 13, 2020. A release of information form to a government agency, signed and dated by the client on July 9, 2020, allowed for the release of Urinary Drug Screenings, which exceeds the limits established by 4 Pa. Code 255.5. These findings were reviewed with facility staff during the licensing process.	Plan of Correction All releases of information will be kept within the limits established by 4 PA Code 255.5 (b). All clinical staff will be trained by the Facility Director in an in-service training on 11/12/2020 regarding these limits as well as the correct use of the release of information form in the electronic health record. The Clinical Supervisor will conduct at least weekly audits of charts in order to ensure compliance. The Quality Assurance department will conduct at least quarterly reviews of the program in order to ensure compliance. The findings of these audits will be reviewed in regular CQI meetings following the audits. The Compliance department will conduct at least annual reviews to ensure compliance with corrective action plan by 12/15/2020.
709.34 (c) (2) LICENSURE Reporting of unusual incidents § 709.34. Reporting of unusual incidents. (c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving: (2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
Observations The project failed to file a written unusual incident report with the Department within 3 business days following an unusual incident involving the death or serious injury due to trauma, suicide, medication error or unusual circumstances. On August 2, 2019, project staff was notified of a client's off-site death. There was no documentation that the unusual incident was reported with the Department at the time of the inspection. On January 27, 2020, project staff was notified of a client's off-site death. There was no documentation that the unusual incident was reported with the Department at the time of the inspection. On April 2, 2020, project staff was notified of a client's off-site death. There was no documentation that the unusual incident was reported with the Department at the time of the inspection. These findings were reviewed with facility staff during the licensing process.	Plan of Correction A written unusual incident report will be filed with the Department within 3 business days following an unusual incident involving a death or serious injury due to trauma, suicide, medication error or unusual circumstances. All staff will be trained by the Facility Director in an in-service training on 11/19/202 regarding these requirements and the Gaudenzia policies related to Incident Reporting. The Quality Assurance department will conduct at least quarterly reviews of the program in order to ensure compliance. The findings of these audits will be reviewed in regular CQI meetings following the audits. The Compliance department will conduct at least annual reviews to ensure compliance with corrective action plan by 12/15/2020
709.34 (c) (4) LICENSURE Reporting of unusual incidents § 709.34. Reporting of unusual incidents. (c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving: (4) Event at the facility requiring the presence of police, fire or ambulance personnel.
Observations The project failed to file a written unusual incident report with the Department within 3 business days following an unusual incident involving an event at the facility requiring the presence of police, fire or ambulance personnel. On June 27, 2019, law enforcement and emergency services personnel responded to the facility. There was no documentation that the unusual incident was reported with the Department at the time of the inspection. On July 8, 2019, emergency services personnel responded to the facility. There was no documentation that the unusual incident was reported with the Department at the time of the inspection. On July 30, 2019, emergency services personnel responded to the facility. There was no documentation that the unusual incident was reported with the Department at the time of the inspection. These findings were reviewed with facility staff during the licensing process.	Plan of Correction A written unusual incident report will be filed with the Department within 3 business days following an unusual incident involving an event at the facility requiring the presence of police, fire or ambulance personnel. All staff will be trained by the Facility Director in an in-service training on 11/19/2020 regarding these requirements and the Gaudenzia policies related to Incident Reporting. The Quality Assurance department will conduct at least quarterly reviews of the program in order to ensure compliance. The findings of these audits will be reviewed in regular CQI meetings following the audits. The Compliance department will conduct at least annual reviews to ensure compliance with corrective action plan by 12/15/2020.
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 The project failed to ensure that counseling services were provided to the client according to the individual treatment and rehabilitation plan in six of seven client records reviewed. Client # 1 was admitted on December 4, 2019 and was discharged on August 3, 2020. A comprehensive treatment plan, dated on January 3, 2020, indicated that the client was to receive two group therapy sessions per week. The chart's record of service and progress notes indicated that the client had only received one group therapy session for the weeks of March 3, 2020 through March 9, 2020, March 10, 2020 through April 6, 2020, April 7, 2020 through April 13, 2020, April 21, 2020 through April 27, 2020, May 5, 2020 through May 11, 2020, May 12, 2020 through May 18, 2020, May 19, 2020 through May 25, 2020, May 26, 2020 through June 1, 2020, June 2, 2020 through June 8, 2020, June 9, 2020 through June 15, 2020 and June 16, 2020 through June 22, 2020. Additionally, the client did not receive any group therapy session during the month of July. Client # 3 was admitted on February 13, 2020 and was a current client at the time of the inspection. A comprehensive treatment plan, dated on March 25, 2020, indicated that the client was to receive one individual counseling session per week. The chart's record of service and progress notes indicated that the client had not received any individual counseling sessions for the weeks of April 14, 2020 through April 20, 2020, July 28, 2020 through August 3, 2020 and September 1, 2020 through September 7, 2020. Client # 4 was admitted on February 13, 2020 and was discharged on October 13, 2020. A comprehensive treatment plan, dated on March 13, 2020, indicated that the client was to receive one individual counseling session and three group counseling sessions per week. The chart's record of service and progress notes indicated that the client had not received any individual counseling sessions for the weeks of March 22, 2020 through March 28, 2020, March 29, 2020 through April 4, 2020, April 12, 2020 through April 18, 2020, April 19, 2020 through April 25, 2020, April 26, 2020 through May 2, 2020, May 3, 2020 through May 9, 2020, July 26, 2020 through August 1, 2020, August 9, 2020 through August 15, 2020, August 16, 2020 through August 22, 2020, August 23, 2020 through August 29, 2020 and October 4, 2020 through October 10, 2020. Additionally, the client did not receive any group therapy counseling session the weeks of July 26, 2020 through August 1, 2020, August 9, 2020 through August 15, 2020, August 16, 2020 through August 22, 2020 August 23, 2020 through August 29, 2020, September 13, 2020 through September 19, 2020 and October 4, 2020 through October 10, 2020. Client # 5 was admitted on May 4, 2020 and was a current client at the time of the inspection. A comprehensive treatment plan, dated on June 4, 2020, indicated that the client was to receive one individual counseling session per week. The chart's record of service and progress notes indicated that the client had not received any individual counseling sessions for the weeks of June 14, 2020 through June 20, 2020 and August 24, 2020 through August 29, 2020. Client # 6 was admitted on February 28, 2020 and was discharged on September 2, 2020. A comprehensive treatment plan, dated on May 22, 2020, indicated that the client was to receive one individual counseling session per week. The chart's record of service and progress notes indicated that the client had not received any individual counseling sessions for the weeks of April 5, 2020 through April 19, 2020, April 26, 2020 through May 2, 2020, June 28, 2020 through July 4, 2020, July 12, 2020 through July 18, 2020, August 16, 2020 through August 22, 2020 and August 23, 2020 through August 29, 2020. Client # 7 was admitted on March 4, 2020 and was a current client at the time of the inspection. A comprehensive treatment plan, dated on March 4, 2020, indicated that the client was to receive one individual counseling session per week. The chart's record of service and progress notes indicated that the client had not received any individual counseling sessions for the weeks of March 22, 2020 through March 28, 2020, March 29, 2020 through April 3, 2020, July 19, 2020 through July 25, 2020, July 26, 2020 through August 1, 2020, August 2, 2020 through August 8, 2020 and September 27, 2020 through October 3, 2020. These findings were reviewed with facility staff during the licensing process.	Plan of Correction Counseling services will be provided according to the individual treatment and rehabilitation plan. All clinical staff will be trained by the Facility Director in an in-service training on 12/3/2020 regarding these requirements. This electronic form will replace our previous system of documenting this in a paper log binder. The Clinical Supervisor will conduct at least weekly audits of charts in order to ensure compliance. The Quality Assurance department will conduct at least quarterly reviews of the program in order to ensure compliance. The findings of these audits will be reviewed in regular CQI meetings following the audits. The Compliance department will conduct at least annual reviews to ensure compliance with corrective action by 12/15/2020