INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on May 3, 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-Harrisburg Concept 90 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
|
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
|
Observations
Based on a review of eleven staff records, the facility failed to ensure that three staff had the mandatory training in communicable diseases within the required time frames.
Staff #9 was hired as Recovery support on December 13, 2010. The staff person was required to have 6 hours of HIV/AIDs and 4 hours of TB/STD training by December 13, 2012, but at the time of the inspection, the staff person had no documentation of training in this area.
Staff # 10 was hired as Recovery support on March 17, 2019. The staff person was required to have 6 hours of HIV/AIDs and 4 hours of TB/STD training by March 17, 2021, but at the time of the inspection, the staff person had no documentation of training in this area.
Staff # 11 was hired as Recovery support on June 30, 2014. The staff person was required to have 6 hours of HIV/AIDs and 4 hours of TB/STD training by June 30, 2016, but at the time of the inspection, the staff person had no documentation of training in this area.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Plan of Correction:
All staff members have completed the required trainings as of 5/27/22.
Going forward, the Program Director will review training plans for all staff members on at least a quarterly basis. Any staff members who are approaching deadlines will be scheduled to complete all required trainings prior to the required timeframe. The first of these reviews will be completed by 6/30/22
The Quality Assurance Department will conduct at least quarterly reviews of all programs, to include a review of all plans of correction to ensure full implementation.
|
705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
|
Observations
Based on a physical site inspection on May 3, 2022, the facility failed to store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
The facility's dumpster was overflowing with trash and the lid could not be shut. There was also additional bagged trash piled next to the dumpster.
These findings were discussed with facility staff during the licensing process.
|
Plan of Correction
Our trash has been picked up once a week on Mondays. Due to increase in population a need for additional trash pick-up was requested for more to the Gaudenzia Maintenance department .We have been informed that a second pick up a week will begin by 6/30/22.
Safety rounds are completed daily to make sure that the dumpster is not overflowing and the lid is closed. Any concerns in this area will be immediately brought to the attention of the Program Director and immediate action take to address the situation. This has been added as a specific item to the run sheet that is completed for each run. These run sheets are maintained in a log and will be reviewed at least monthly by the Program Director.
The Quality Assurance Department will conduct at least quarterly reviews of all programs, to include a review of all plans of correction to ensure full implementation.
|
705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
|
Observations
Based on a physical plant inspection on May 3, 2022, the facility failed to provide slip-resistant surfaces in all bathtubs and showers.
There were no slip-resistant surfaces in the men's showers.
These findings were discussed with facility staff during the licensing process.
|
Plan of Correction
The slip-resistant mats had been temporarily removed for cleaning and had not been replaced at the time of the visit. They were replaced on 5/3/22 and are currently installed.
Daily safety rounds will include inspection of all bathrooms and presence of slip-resistant mats. Any concerns in this area will be immediately brought to the attention of the Program Director and immediate action take to address the situation. This has been added as a specific item to the run sheet that is completed for each run. These run sheets are maintained in a log and will be reviewed at least monthly by the Program Director.
The Quality Assurance Department will conduct at least quarterly reviews of all programs, to include a review of all plans of correction to ensure full implementation.
|
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.
|
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.
|
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.
9/30/22
|
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
|
Observations
Based on a review of client records, the project failed to notify one applicable client, in writing, of a decision to involuntarily terminate the client's treatment at the project.
Client #7 was admitted on January 6, 2022 and was discharged on February 8, 2022. The client record did not have documentation in writing of the project's decision to involuntary discharge the client's treatment at the project.
These findings were discussed with project staff during the licensing process.
|
Plan of Correction
Staff will be re-trained in an in-service on 6/2/22 conducted by the Clinical Supervisor regarding notification of termination requirements, and how to properly document this in the record.
An internal tracking tool for each chart has been developed to help remind staff of upcoming documentation requirements. This includes notification of termination.
Notification of Termination will be added to our Gaudenzia quantitative audit tool in order to monitor completion. This will occur no later than 6/10/22.
The Clinical Supervisor will conduct weekly audits of a sample of charts in order to ensure that notification of termination is completed for all involuntarily discharged clients. Any missing documentation will be brought to the attention of the clinician and completed within 48 hours.
The Program Director will conduct monthly audits of a sample of charts. Any missing documentation will be brought to the attention of the Clinical Supervisor 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.
|
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.
|
Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in four out of seven client records reviewed.
Client #1 was admitted on February 17, 2022 and was still current at the time of the inspection. A treatment plan update was completed on April 2, 2022, and the next update was due by May 2, 2022; however, there were no additional treatment plans documented in the client record at the time of inspection.
Client #2 was admitted on March 4, 2022 and was current at the time of the inspection. There was one treatment plan update on March 18, 2022 with the next update due no later than April 18, 2022; however, one was not documented until April 22, 2022.
Client #4 was admitted on February 11, 2022 and was current at the time of the inspection. A treatment plan update was completed on February 25, 2022 with the next update due no later than March 25, 2022; however, one was not documented until May 2, 2022.
Client #5 was admitted on July 31, 2021 and was discharged on October 25, 2021. A treatment plan update was completed on August 1, 2021 with the next update due no later than September 1, 2021; however, one was not documented until September 4, 2021.
These findings were reviewed with facility staff during the licensing process.
This was a repeat citation from a licensing inspection that took place on May 3, 2021.
|
Plan of Correction
Staff will be re-trained in an in-service on 6/2/22 conducted by the Clinical Supervisor regarding treatment plan updates, and how to properly document this in the record.
An internal tracking tool for each chart has been developed to help remind staff of upcoming documentation requirements. This includes treatment plan updates. The Clinical Supervisor will send a reminder to clinicians at the beginning of each month noting which clients are due for Treatment Plan updates. Clinical staff will send all treatment plans to Clinical Supervisor for approval. Calendars are being utilized to keep close track of time-sensitive dates for each client. Upcoming updated treatment plans will be reviewed in weekly Clinical Staff meeting.
The Clinical Supervisor will conduct weekly audits of a sample of charts in order to ensure that timely treatment plan updates are completed for all charts. Any missing documentation will be brought to the attention of the clinician and completed within 48 hours.
The Program Director will conduct monthly audits of a sample of charts in order to ensure that timely treatment plan updates are completed for all charts. Any missing documentation will be brought to the attention of the Clinical Supervisor 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. conducted by the Clinical Supervisor regarding this regulation, and how to properly document this in the record.
|
709.53(a)(8) LICENSURE Case Consultation Notes
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:
(8) Case consultation notes.
|
Observations
Based on a review of seven client records, the project failed to include case consultation notes in three out of three applicable records reviewed.
Client #5 was admitted on July 31, 2021 and discharged on October 25, 2021. Client #5 did not have a case consultation documented in their record at the time of the inspection.
Client #6 was admitted on September 1, 2021 and discharged on November 3, 2021. Client #6 did not have a case consultation documented in their record at the time of the inspection.
Client #7 was admitted on January 6, 2022 and discharged on February 8, 2022. Client #7 did not have a case consultation documented in their record at the time of the inspection.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Staff will be re-trained in an in-service on 6/2/22 conducted by the Clinical Supervisor regarding case consultation notes, and how to properly document this in the record.
An internal tracking tool for each chart has been developed to help remind staff of upcoming documentation requirements. This includes case consultation notes. The Clinical Supervisor will send a reminder to clinicians at the beginning of each month noting which clients are due for case consultations. Clinical staff will send all case consultations to Clinical Supervisor and other participating staff members for approval. Calendars are being utilized to keep close track of time-sensitive dates for each client. Upcoming case consults will be reviewed in weekly Clinical Staff meeting.
The Clinical Supervisor will conduct weekly audits of a sample of charts in order to ensure that timely case consultations are completed for all charts. Any missing documentation will be brought to the attention of the clinician and completed within 48 hours.
The Program Director will conduct monthly audits of a sample of charts. Any missing documentation will be brought to the attention of the Clinical Supervisor 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.
|
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.
|
Observations
Based on a review of seven client records, the project failed to have a complete client record on one of three applicable clients that included information relative to the client's involvement with the project, including follow-up information.
Client #5 was admitted on July 31, 2021 and was discharged on October 25, 2021. Client #5 did not have documentation of follow-up information in the client record.
These findings were reviewed with project staff during the licensing process.
This is a repeat citation from a licensing inspection held on May 3, 2021.
|
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.
Staff will be re-trained in an in-service on 6/2/22 conducted by the Clinical Supervisor 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 Clinical Supervisor 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 Clinical Supervisor 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.
The Clinical Supervisor will conduct weekly audits of a sample of charts in order to ensure that follow-ups are completed for all discharged charts. Any missing documentation will be brought to the attention of the clinician and completed within 48 hours.
The Program Director will conduct monthly audits of a sample of discharged charts. Any missing documentation will be brought to the attention of the Clinical Supervisor 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.
|
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.
|
Observations
Based on a review of client records, the facility failed to verify that work done by the clients at the project is an integral part of their treatment and rehabilitation plan in three out of seven client records reviewed.
Client # 2 was admitted on March 4, 2022 and was still current at the time of the inspection. Client #2 did not have a work goal in their treatment plans dated March 4, 2022, March 18, 2022 and April 22, 2022.
Client # 3 was admitted on March 14, 2022 and was still current at the time of the inspection. Client #3 did not have a work goal in their treatment plans dated March 21, 2022 and April 5, 2022.
Client # 4 was admitted on February 11, 2022 and was still current at the time of the inspection. Client #4 did not have a work goal in their treatment plans dated February 12, 2022, February 25, 2022 and May 2, 2022.
These findings were discussed with facility staff during the inspection process.
This is a repeat citation from a licensing inspection conducted October 15, 2020, and a licensing inspection conducted on May 3, 2021.
|
Plan of Correction
Plan of Correction:
Staff will be re-trained in an in-service on 6/2/22 conducted by the Clinical Supervisor regarding this regulation, and how to properly document this in the record. The Clinical Supervisor will review the treatment plan form, and the specific areas designed to be used to indicate this.
The Clinical Supervisor will conduct weekly audits of a sample of charts in order to ensure that treatment plans properly document work as treatment. Any missing documentation will be brought to the attention of the clinician and completed within 48 hours.
The Program Director will conduct monthly audits of a sample of charts. Any missing documentation will be brought to the attention of the Clinical Supervisor 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.
|