INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 13, 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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705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on a physical plant inspection on May 13, 2024, the facility failed to ensure that exits from the nonresidential facility were unobstructed. The emergency exit door through the group room door was obstructed, as it was locked.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On May 29th, 2024, Clinical Supervisor met with landlord of the building asked permission to have the emergency exit door through the group room unlocked during our business hours. Landlord agreed. A sign will be posted on the door notifying everyone it is an exit by 6/14/24.
Clinical Supervisor and/or staff have begun unlocking the door during office hours. They then re-lock when the program is closed. During monthly health and safety report completion, the Clinical Supervisor will check to ensure it is unlocked on that report. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that one applicable staff member was trained to perform assigned tasks during emergencies prior to being on shift.
Employee # 4 was hired as a counselor on August 7, 2023 and is current in that position. Employee # 4 began working shifts on August 7, 2023; however, and the personnel record did not contain documentation that the employee was trained to perform assigned tasks during emergencies prior to being on shift.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
May 22nd, 2024- Division Director provided Clinical Supervisor of the program with a training certificate that is specific to Fire Extinguishers/Emergency Evacuation Procedures. CS was instructed to use this for any new hires to the program within 7 days of start date. CS was also asked to complete the training with employee # 4 and upload the certificate into our Relias Training Program. This will be completed by staff and uploaded by the Supervisor by 6/22/24. |
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.
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Observations
Based on a review of seven client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in two records reviewed.
Client # 1 was admitted on September 15, 2023 and was discharged on February 1, 2024. Per a discussion with the Clinical Supervisor, information such as client diagnosis was disclosed to the funding source, however, the consent to release information form to the funding source signed by the client on September 11, 2023, did not allow for the release of that information. A revised consent to release information to the funding source, which included the release of the client ' s diagnosis, was not completed until October 18, 2023.
Client # 6 was admitted on February 14, 2024 and was active at the time of the inspection. Per a discussion with the Clinical Supervisor, information such as client diagnosis was disclosed to the funding source, however, the consent to release information form to the funding source signed by the client on February 6, 2024, did not allow for the release of that information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On May 29th, 2024 a meeting was held about releases of information, consents with all staff. The CS will review weekly the assessments completed to ensure the workflow is being followed by all counselors. Any noted outstanding releases/request of information will addressed at that time with counselor to fix. For Client #6 the release of information will be obtained no later than 6/30/24. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records and the facility's policies and procedures, the facility failed to document a psychosocial evaluation, within 30 days of admission as per policy, in six of six applicable records reviewed.
Client # 1 was admitted on September 15, 2023 and was discharged on February 1, 2024. The record did not contain a psychosocial evaluation.
Client # 2 was admitted on November 7, 2023 and was discharged on March 10, 2024. The psychosocial evaluation was not completed until February 12, 2024.
Client # 4 was admitted on January 9, 2024 and was discharged on March 8, 2024. The psychosocial evaluation was not completed until February 20, 2024.
Client # 5 was admitted on August 8, 2023 and was active at the time of the inspection. The record did not contain a psychosocial evaluation.
Client # 6 was admitted on February 14, 2024 and was active at the time of the inspection. The record did not contain a psychosocial evaluation.
Client # 7 was admitted on September 19, 2023 and was active at the time of the inspection. The record did not contain a psychosocial evaluation.
This is a repeat citation from the June 13, 2023 annual licensing renewal inspection.
These finding were discussed with facility staff during the licensing process.
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Plan of Correction
On May 29th, the Clinical Supervisor reviewed the workflow with the counselors, and counselors are now required to use it and submit it to the Clinical Supervisor weekly for verification of the completion of the required documentation including the psychosocial histories for the next 60 days. |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on a review of client records and the facility policies and procedures, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include progress notes completed immediately after therapy sessions, in five of seven records reviewed.
Client # 1 was admitted on September 15, 2023 and was discharged on February 1, 2024. The record contained a progress note for an individual session occurring on December 20, 2023, that was not completed until January 7, 2024. Additionally, the record contained a progress note for a group session occurring on December 15, 2023, that was not completed until January 15, 2024.
Client # 2 was admitted on November 7, 2023 and was discharged on March 10, 2024. The record contained a progress note for an individual session occurring on December 12, 2023, that was not completed until December 19, 2023. Additionally, the record contained progress notes for group sessions occurring on December 8, 2023 and December 14, 2023, that were not completed until January 2, 2024 and December 26, 2023, respectively.
Client # 3 was admitted on April 13, 2023 and was discharged on January 11, 2024. The record contained a progress note for an individual session occurring on November 15, 2023, that was not completed until November 26, 2023.
Client # 5 was admitted on August 8, 2023 and was active at the time of the inspection. The record contained progress notes for individual sessions occurring on November 22, 2023 and December 8, 2023 and December 29, 2023, that were not completed until November 28, 2023 and January 7, 2024, respectively.
Client # 7 was admitted on September 19, 2023 and was active at the time of the inspection. The record contained progress notes for individual sessions occurring on January 30, 2024 and February 6, 2024, that were not completed until February 12, 2024 and February 26, 2024, respectively.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On June 12th, 2024 supervision is scheduled to review the completion of individual notes immediately after the therapy session. The Clinical Supervisor will be reviewing the schedule to ensure that clinicians have the necessary time allotted to have all notes completed by week's end. Clinical supervisor will run weekly service report on Friday afternoon to ensure notes are completed. If the pattern of late submission occurs, corrective action measures will take place. |
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 seven client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include case consultation notes quarterly, per the facility's policy, in five of five applicable records reviewed.
Client # 1 was admitted on September 15, 2023 and was discharged on February 1, 2024. The client record did not contain documentation of case consultation notes.
Client # 2 was admitted on November 7, 2023 and was discharged on March 10, 2024. The first case consultation note was due to be completed by February 7, 2024; however, it was not completed until February 22, 2024.
Client # 3 was admitted on April 13, 2023 and was discharged on January 11, 2024. The client record did not contain documentation of case consultation notes.
Client # 5 was admitted on August 8, 2023 and was active at the time of the inspection. The client record did not contain documentation of case consultation notes.
Client # 7 was admitted on September 19, 2023 and was active at the time of the inspection. The client record did not contain documentation of case consultation notes.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On May 29th, the Clinical Supervisor will begin to run the Clinical Forms Audit report monthly and send out emails to all staff of case consultations coming due. The Clinical Supervisor will ensure that these case consults are completed during clinical staff meetings that are held bi-weekly |
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 client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include a discharge summary within one week of discharge, in three of four applicable records reviewed.
Client # 1 was admitted on September 15, 2023 and was discharged on February 1, 2024. The record did not contain a discharge summary.
Client # 3 was admitted on April 13, 2023 and was discharged on January 11, 2024. The record did not contain a discharge summary.
Client # 4 was admitted on January 9, 2024 and was discharged on March 8, 2024. The discharge summary was not completed until May 12, 2024.
This is a repeat citation from the June 13, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Starting May 29th, 2024 Clinical Supervisor will run the discharge analysis report weekly and send emails to counselors of outstanding discharge paperwork. After the staff meeting on May 29th, counselors will be given one hour of paperwork time dedicated to discharge paperwork per week that must be completed |