INITIAL COMMENTS
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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 28, 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 Coal Township 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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705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, the facility failed to ensure privacy in the counselor's office within the male unit so that counseling session cannot be seen or heard from outside.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Program Director and Clinical Supervisor has ensured patient privacy by installing a solid window curtain in the counseling office located in the male unit. The Program Director will be responsible for ensuring all windows located in the counseling offices have adequate curtains or blinds to ensure ongoing patient privacy. |
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 outpatient client records, there was no documentation that the clients received counseling services according to their individual comprehensive treatment plan in four records reviewed.
Client #1 was admitted on May 19, 2020 and was still active at the time of the inspection. The treatment plan update, dated September 16, 2020, indicated one group session a week and one individual session a week. The record of service and progress notes indicated that the client has not received a group session since September 2, 2020 and an individual session since September 14, 2020.
Client #2 was admitted on April 6, 2020 and was still active at the time of the inspection. The treatment plan update, dated August 4, 2020, indicated one group session a week and one individual session a week. The record of service and progress notes indicated that the client has not received a group session since October 15, 2020 and an individual session since September 22, 2020.
Client #3 was admitted on August 26, 2020 and was still active at the time of the inspection. The treatment plan update, dated September 16, 2020, indicated one group session a week and one individual session a week. The record of service and progress notes indicated that the client has not received any group session since admission and the last individual session was on September 30, 2020.
Client #4 was admitted on April 30, 2020 and was still active at the time of the inspection. The treatment plan update, dated July 29, 2020, indicated one group session a week and one individual session a week. The record of service and progress notes indicated that the client had not received any groups since admission.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
A mandatory in-service training occurred on November 13, 2020 and addressed Clinical staff on treatment management procedures specific to assuring that counseling services are provided according to the individual plan and treatment plan updates. All staff will be directed to schedule clients according to their treatment recommendation. Any deviation from the set course of treatment will be documented in the progress notes. The Clinical Supervisor will review treatment plan recommendations monthly and compare it to the record of service for compliance during the internal CQI process. Clinical staff will be monitored monthly in regular supervisory sessions as well as weekly during the Clinical team meetings. The Quality Assurance Department will conduct quarterly chart audits. The compliance department will conduct annual reviews to ensure that all action steps on this correction action plan have been implemented. |