INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 15, 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 DRC 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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709.28 (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 client records, the facility failed to obtain a written informed and voluntary consent to release information form from the client for the disclosure of information contained in the client record in one of seven client records reviewed.
Client #1 was admitted on January 28, 2021 and was discharged May 10, 2021. The record did not contain a consent to release information form to the funding source signed by the client, however, there was evidence of billing.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Informed consents will be obtained for any information to be disclosed from the client record.
The consent form has been revised within our Electronic Health Record to ensure that it cannot be finalized until it is signed by the client and clinical staff, indicating the disclosure of information being authorized.
The Program Director will facilitate an in-service staff training on completing consent to release information forms at staff meeting on January 25, 2022
The Program Director/Clinical Supervisor will audit a sample of clinical charts at least monthly, to include a review of consent forms to ensure that all areas have been completed, including the required signatures. Any deficiencies noted will be addressed with specific clinicians in clinical supervision and corrections made within 3 days.
The Quality Assurance department will conduct at least quarterly reviews to include audits of clinical records, the findings of which will be discussed with the program, and action steps developed.
The Compliance department will conduct a review of all Plans of Correction within 9 months to ensure full implementation.
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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.
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Observations
Based on a review of seven client records, the facility failed to ensure that consent to release information forms included the specific information to be disclosed in one record reviewed.
Client #1 was admitted on January 28, 2021 and was discharged May 10, 2021. The record contained a consent to release information form to the funding source, a lab, and three legal entities signed by the witness on January 28, 2021 that were missing the specific information to be disclosed.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
Consents will be completed for all disclosures and include the specific information to be disclosed.
The consent form has been revised within our Electronic Health Record to ensure that it cannot be finalized unless it addresses all required areas.
The Program Director will facilitate an in-service staff training on completing consent to release information forms at staff meeting on January 25, 2022
The Program Director/Clinical Supervisor will audit a sample of clinical charts at least monthly, to include a review of consent forms to ensure that all areas have been completed, including the specific information to be disclosed. Any deficiencies noted will be addressed with specific clinicians in clinical supervision and corrections made within 3 days.
The Quality Assurance department will conduct at least quarterly reviews to include audits of clinical records, the findings of which will be discussed with the program, and action steps developed.
The Compliance department will conduct a review of all Plans of Correction within 9 months to ensure full implementation.
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709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of seven client records, the facility failed to ensure that consent to release information forms included the purpose of disclosure in one record reviewed.
Client #1 was admitted on January 28, 2021 and was discharged May 10, 2021. The record contained a consent to release information form to the funding source, a lab, and three legal entities signed by the witness on January 28, 2021 that were missing the purpose of disclosure.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
Consents will be completed for all disclosures and include the purpose of disclosure.
The consent form has been revised within our Electronic Health Record to ensure that it cannot be finalized unless it addresses all required areas.
The Program Director will facilitate an in-service staff training on completing consent to release information forms at staff meeting on January 25, 2022
The Program Director/Clinical Supervisor will audit a sample of clinical charts at least monthly, to include a review of consent forms to ensure that all areas have been completed, including the purpose of disclosure. Any deficiencies noted will be addressed with specific clinicians in clinical supervision and corrections made within 3 days.
The Quality Assurance department will conduct at least quarterly reviews to include audits of clinical records, the findings of which will be discussed with the program, and action steps developed.
The Compliance department will conduct a review of all Plans of Correction within 9 months to ensure full implementation.
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709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of seven client records, the facility failed to ensure that consent to release information forms included the dated signature of the client in one record reviewed.
Client #1 was admitted on January 28, 2021 and was discharged May 10, 2021. The record contained a consent to release information form to the funding source, a lab, and three legal entities signed by the witness on January 28, 2021 that were missing the dated signature of the client.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
Informed consents will include dated signature of the client.
The consent form has been revised within our Electronic Health Record to ensure that it cannot be finalized until it is signed by the client and clinical staff, including the dated signature of the client.
The Program Director will facilitate an in-service staff training on completing consent to release information forms at staff meeting on January 25, 2022
The Program Director/Clinical Supervisor will audit a sample of clinical charts at least monthly, to include a review of consent forms to ensure that all areas have been completed, including the dated signature of the client. Any deficiencies noted will be addressed with specific clinicians in clinical supervision and corrections made within 3 days.
The Quality Assurance department will conduct at least quarterly reviews to include audits of clinical records, the findings of which will be discussed with the program, and action steps developed.
The Compliance department will conduct a review of all Plans of Correction within 9 months to ensure full implementation.
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709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of seven client records, the facility failed to ensure that consent to release information forms included the date, event, or condition upon which the consent will expire in one record reviewed.
Client #3 was admitted on July 1, 2020 and was discharged October 28, 2021. The record contained a consent to release information form to the funding source signed by the client on July 1, 2020 that was missing the date, event, or condition upon which the consent will expire.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
Informed consents will include date, event or condition upon which the consent will expire.
The consent form has been revised within our Electronic Health Record to ensure that it cannot be finalized until it is signed by the client and clinical staff, including the date, event or condition upon which the consent will expire.
The Program Director will facilitate an in-service staff training on completing consent to release information forms at staff meeting on January 25, 2022
The Program Director/Clinical Supervisor will audit a sample of clinical charts at least monthly, to include a review of consent forms to ensure that all areas have been completed, including the date, event or condition upon which the consent will expire. Any deficiencies noted will be addressed with specific clinicians in clinical supervision and corrections made within 3 days.
The Quality Assurance department will conduct at least quarterly reviews to include audits of clinical records, the findings of which will be discussed with the program, and action steps developed.
The Compliance department will conduct a review of all Plans of Correction within 9 months to ensure full implementation.
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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 ensure that treatment and rehabilitation plans were reviewed and updated at least every 60 days in two of four records reviewed.
Client #3 was admitted on July 1, 2020 and discharged on October 29, 2021. The comprehensive treatment plan was completed on August 6, 2020 and a treatment plan update was due by October 6, 2020; however, the next update was not completed until August 18, 2021.
Client #4 was admitted on April 7, 2021 and discharged on September 13, 2021. The comprehensive treatment plan was completed on May 3, 2021 and an update was due by July 3, 2021; however, the next update was not completed until August 16, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
The treatment and plan will be reviewed and updated at least every 60 days.
Treatment plan updates will be documented in the client record.
The Program Director will facilitate an in-service staff training on treatment plan updates on 1/25/22.
The Program Director/Clinical Supervisor will audit a sample of clinical charts at least monthly, to include a review of treatment plan updates. Any deficiencies noted will be addressed with specific clinicians in clinical supervision and corrections made within 3 days.
The Quality Assurance department will conduct at least quarterly reviews to include audits of clinical records, the findings of which will be discussed with the program, and action steps developed.
The Compliance department will conduct a review of all Plans of Correction within 9 months to ensure full implementation.
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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.
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Observations
Based on a review of seven client records, the facility failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plans in four records reviewed.
Client #2 was admitted on June 30, 2021 and was discharged on October 1, 2021. The preliminary treatment plan completed on June 30, 2021 indicated the frequency of individual sessions to be weekly; however, no individual sessions were held during the weeks of July 12, 2021, July 19, 2021, or August 2, 2021.
Client #3 was admitted on July 1, 2020 and was discharged on October 29, 2021. The comprehensive treatment plan completed on August 6, 2020 and not updated until August 18, 2021 indicated the frequency of group counseling sessions to be weekly; however, no group sessions were held June 30, 2021 and August 18, 2021.
Client #5 was admitted on March 22, 2021 and was discharged on July 14, 2021. The treatment plans completed on March 22, 2021, April 21, 2021, and June 2, 2021 each indicated the frequency of individual sessions to be weekly; however, no individual sessions were held the weeks of April 5, 2021, April 26, 2021, May 24, 2021, and July 5, 2021.
Client #6 was admitted on August 17, 2021 and was active at the time of inspection. The preliminary treatment plan completed on August 17, 2021 indicated the frequency of individual sessions to be weekly; however, no individual sessions were held between August 23, 2021 and December 9, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counseling services will be provided according to the treatment plan.
Delivery of counseling services will be documented in the client record.
Client #6 - chart will be reviewed and required individual session documentation will be uploaded per Avatar billing for individual services. No show notes will also be included.
The Inpatient Program Director will facilitate an in-service staff training on treatment plan adherence and documentation of individual counseling sessions on 1/25/22.
The Program Director/Clinical Supervisor will audit a sample of clinical charts at least monthly, to include a review of treatment plan updates. Any deficiencies noted will be addressed with specific clinicians in clinical supervision and corrections made within 3 days.
The Quality Assurance department will conduct at least quarterly reviews to include audits of clinical records, the findings of which will be discussed with the program, and action steps developed.
The Compliance department will conduct a review of all Plans of Correction within 9 months to ensure full implementation.
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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, the facility failed to ensure a complete client record on an individual which includes information relative to the client's involvement with the project including case consultation notes in five records reviewed.
Client #3 was admitted on July 1, 2020 and was discharged on October 29, 2021. The client record did not contain documentation of case consultation notes after January 27, 2021, and they should have been completed at least every sixty days per the facility ' s policy.
Client #4 was admitted on April 7, 2021 and discharged on September 13, 2021. The client record did not contain documentation of case consultation notes after April 20, 2021, and they should have been completed at least every sixty days per the facility ' s policy.
Client #5 was admitted on March 22, 2021 and was discharged on July 14, 2021. The client record did not contain documentation of case consultation notes, and they should have been completed at least every sixty days per the facility ' s policy.
Client #6 was admitted on August 17, 2021 and was active at the time of inspection. The client record did not contain documentation of case consultation notes, and they should have been completed at least every sixty days per the facility ' s policy.
Client #7 was admitted on May 28, 2021 and was active at the time of inspection. The client record did not contain documentation of case consultation notes, and they should have been completed at least every sixty days per the facility ' s policy.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
The client record will include documentation of case consultation notes at least every 90 days.
The Gaudenzia Policy will be revised by the Director of Regulatory Standards to specify that Case Consultation Notes will be completed at least every 90 days. This revision will be made by 1/31/22.
The Program Director will facilitate an in-service staff training on completion of case consultation notes on 1/25/22.
The Program Director/Clinical Supervisor will audit a sample of clinical charts at least monthly, to include a review of case consultation notes. Any deficiencies noted will be addressed with specific clinicians in clinical supervision and corrections made within 3 days.
The Quality Assurance department will conduct at least quarterly reviews to include audits of clinical records, the findings of which will be discussed with the program, and action steps developed.
The Compliance department will conduct a review of all Plans of Correction within 9 months to ensure full implementation.
Client #6 electronic chart will be reviewed by Outpatient Program Supervisor and Case Consultations will be entered into open Avatar chart as required.
Client #7 electronic chart will be reviewed by Outpatient Program Supervisor and Case Consultations will be entered into open Avatar chart as required.
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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 seven client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include follow-up information in four records reviewed.
Client #1 was admitted on January 28, 2021 and discharged on May 10, 2021. The client record did not contain documentation of follow-up information.
Client #2 was admitted on June 30, 2021 and discharged on October 1, 2021. The client record did not contain documentation of follow-up information.
Client #4 was admitted on April 7, 2021 and discharged on September 13, 2021. The client record did not contain documentation of follow-up information.
Client #5 was admitted on March 22, 2021 and discharged on July 14, 2021. The client record did not contain documentation of follow-up information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clients will be contacted post-discharge to obtain follow-up information.
Follow up information shall be obtained for each client post-discharge. If there is difficulty contacting the client, there will be documentation of each follow up attempt using the Follow-Up Contact Note in the electronic health record.
Primary Counselors and/or designee of the Program/Clinical Supervisor or Director shall assume responsibility for client follow-up.
The Program Director will facilitate an in-service staff training on to include discussion of follow-up requirements on January 25, 2022
The Program Director/Clinical Supervisor will audit a sample of clinical charts at least monthly, to include a review of follow-up documentation.
The Quality Assurance department will conduct at least quarterly reviews to include audits of clinical records, the findings of which will be discussed with the program, and action steps developed.
The Compliance department will conduct a review of all Plans of Correction within 9 months to ensure full implementation.
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