INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 19-21, 2024 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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709.92(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 client records, the facility failed to review and update treatment and rehabilitation plans within 60 days in three of six client records.
Client #2 was admitted on December 28, 2023 and discharged on May 30, 2024. A treatment plan was completed on January 23, 2024 and an update was due by March 23, 2024 but not completed until April 2, 2024.
Client #4 was admitted on February 12, 2024 and still a current client. A treatment plan was completed on February 12, 2024 and an update was due by April 12, 2024 but not completed until July 17, 2024.
Client #6 was admitted on January 9, 2024 and still a current client. A treatment plan was completed on March 28, 2024 and an update was due by May 27, 2024 but not completed until June 18, 2024.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the September 12, 2022 and September 20, 2023 licensure renewal inspections.
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Plan of Correction
Clinical Director will review documentation standards and workflow as it relates to treatment plan updates with all staff by 10/1/2024. Clinical Director will review treatment plan analysis report with Counselors weekly to identify upcoming plans that are due. Clinical Director (weekly), Division Director (quarterly), and CQI Department (biannually) will conduct audits of charts to ensure compliance. Any issues noted will be addressed by the Clinical Supervisor with the clinician in a documented Clinical Supervision Session, and corrected within 48 hours. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to complete case consultations in five of six applicable records reviewed. Per agency policy and procedures, case consultations are to be completed within 90 days of admission.
Client #2 was admitted on December 28, 2023 and discharged on May 30, 2024. There was no documentation of a case consultation being completed for this client.
Client #4 was admitted on February 12, 2024 and still a current client. There was no documentation of a case consult being completed for this client.
Client #5 was admitted on January 17, 2024 and still a current client. There was no documentation of a case consult being completed for this client.
Client #6 was admitted on January 9, 2024 and still a current client. There was no documentation of a case consult being completed for this client.
Client #7 was admitted on April 24, 2024 and still a current client. There was no documentation of a case consult being completed for this client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will review documentations standards as it relates to Case Consultations by 10/1/2024. Administrative staff will run a weekly census to determine which client are due for case consults and distribute weekly. Clinicians will complete identified case consults. Clinical Director (monthly), Division Director(quarterly) and CQI department (biannually) will complete chart audits to ensure compliance. Any issues noted will be addressed by the Clinical Supervisor with the clinician in a documented Clinical Supervision Session, and corrected within 48 hours. |
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 client records, the facility failed to document follow-up information in two of three discharged records.
The facility's policy and procedure manual states follow up contact is to be completed for all discharges within 30 days.
There was no follow up information documented in client records #1 and #2.
Client #1 was admitted on February 21, 2024 and was discharged on May 28, 2024.
Client #2 was admitted on December 28, 2023 and was discharged on May 30, 2024.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Clinical Director will review timelines for discharge with all staff by 10/1/2024. Clinicians will discharge clients in the required timeframe. A report will be run weekly to identify discharges clients to complete follow-up. A report will also be run at the end of the month to ensure all clients have been identified. All follow-ups will be completed within 30 days. Follow-up contacts will be monitored in chart audits Monthly by the Clinical Director, quarterly by the Division Director and Biannually by the CQI manger. Any deficiencies identified will be corrected within 48 hours. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for treatment plan updates were submitted and approved by the Department for the September 12, 2022 and September 20, 2023 annual licensing inspections. Treatment plan updates were again found to be a deficiency in the August 21, 2024 licensing inspection.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Division Director will review current and past POC to with Clinical Director by 10/1/2024 and at least monthly in supervision. Chart Audits will be conducted Monthly by Clinical Director, Quarterly by Division Director and Biannually by CQI Department. Division Director and Clinical Director will review findings monthly. CQI and Outpatient Department will review findings during biannual audit meetings to ensure compliance with POC. Deficiencies will be addressed with Clinicians through documented performance improvement plans and progressive corrective action. |