INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 30, 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 Montgomery County Outpatient 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on the review of five personnel records, the project failed to ensure that a clinical supervisor that has not functioned for two years as a supervisor in the provision of clinical services complete a core curriculum in clinical supervision.
Employee #3 was hired as a clinical supervisor on February 6, 2020 and was a current employee at the time of the inspection. Since employee #3 had not functioned for two-years as a supervisor in the provision of clinical services, the employee would need to complete a core curriculum in clinical supervision. The employee had not completed a core curriculum in clinical supervision as of the date of the inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will be scheduled for the clinical supervision training at the earliest opportunity. The Program Director will monitor all staff training files on a quarterly basis to ensure that all staff receive required training in a timely manner. The Compliance department will review plans of correction at least annually to ensure implementation. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on the review of the fire drill log from July 2020 through May 2020, the facility failed to maintain written fire drill records that included whether the fire alarm or smoke detector was operative.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
It was found that the program was using an outdated version of the fire drill log, which did not monitor for those items. The program is now using the correct version of the log. The Program Director will monitor to ensure compliance through monthly review of the fire drill log. The Program Director will follow up on any inconsistencies in supervision sessions. The Quality Assurance department will conduct quarterly program review, and the Compliance department will review the plan of correction at least annually to ensure implementation. |
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 client records, the project failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in one of seven client records reviewed.
Client #4 was admitted on November 13, 2020 and was discharged on March 24, 2021. A release of information form to the funding source, signed and dated by the client on November 13, 2020, allowed for the release of Psychological/psychiatric evaluations, case consultation, mental health records, discharge summary, progress notes, medication records and assessments, all of which exceeds the limits established by 4 Pa. Code 255.5. Additionally, A release of information form to a probation agency, signed and dated by the client on November 13, 2020, allowed for the release of psychological/psychiatric evaluations, treatment plans, discharge summary, medication records and assessments.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Any release forms including more than the allowable information will be voided, and a new release form fully completed by 7/13/2021 including the identification of the specific information to be released. All staff have been trained regarding the requirement to obtain a dated signature of the client. This training occurred on 7/13/2021. The Program Director will monitor to ensure compliance through monthly audits of clinical records, and follow up on any inconsistencies in clinical supervision sessions. The Quality Assurance department will conduct quarterly program review, and the Compliance department will review the plan of correction at least annually to ensure implementation. |
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 the review of client records, the project failed to ensure that counseling services are provided according to the individual treatment and rehabilitation plan in five of seven client records reviewed.
Client #1 was admitted on January 7, 2021 and was an active client at the time of the inspection. A comprehensive treatment and rehabilitation plan, documented in the client record on March 5, 2021, indicated that the client was to receive one individual counseling session per week; however, there was no individual counseling sessions documented in the client record from the weeks of March 21, 2021 through March 27, 2021, March 28, 2021 through April 3, 2021, May 9, 2021 through May 15, 2021, May 16, 2021 through May 22, 2021, May 31, 2021 through June 5, 2021 and June 20, 2021 through June 26, 2021.
Client #2 was admitted on February 25, 2021 and was an active client at the time of the inspection. A comprehensive treatment and rehabilitation plan, documented in the client record on April 1, 2021, indicated that the client was to receive one individual counseling session per week; however, there was no individual counseling sessions documented in the client record from the weeks of April 18, 2021 through April 24, 2021, April 25, 2021 through May 1, 2021, May 2, 2021 through May 8, 2021 and May 9, 2021 through May 15, 2021.
Client #4 was admitted on November 13, 2020 and was discharged on March 24, 2021. A comprehensive treatment and rehabilitation plan, documented in the client record on November 13, 2021, indicated that the client was to receive one individual counseling session per week; however, there was no individual counseling sessions documented in the client record from the weeks of November 15, 2020 through November 21, 2020, November 22, 2020 through November 28, 2020, December 6, 2020 through December 12, 2020, December 20, 2020 through December 26, 2020, January 10, 2021 through January 16, 2021 and January 31, 2021 through February 27, 2021.
Client #5 was admitted on December 18, 2020 and was discharged on February 12, 2021. A comprehensive treatment and rehabilitation plan, documented in the client record on December 18, 2021, indicated that the client was to receive one individual counseling session per week; however, there was no individual counseling sessions documented in the client record from the weeks of January 17, 2021 through January 23, 2021, January 24, 2021 through January 30, 2021 and January 31, 2021 through February 6, 2021.
Client #6 was admitted on November 18, 2020 and was discharged on March 8, 2021. A comprehensive treatment and rehabilitation plan, documented in the client record on November 13, 2021, indicated that the client was to receive one individual counseling session per week; however, there was no individual counseling sessions documented in the client record from the weeks of February 21, 2021 through March 6, 2021.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Clinicians will document in the chart the reasons for any no-show, or re-scheduled appointments, including interventions utilized to attempt to motivate individuals to attend treatment sessions as indicated on the Treatment Plan. In addition, for clients who have demonstrated attendance issues, clinicians will document attempts to contact these clients to remind them of upcoming appointments. All staff have been trained regarding the requirement to provide counseling services according to the individual treatment and rehabilitation plan as well as how and when to document no-shows and motivational interventions. This training occurred on 7/13/2021. The Program Director will monitor to ensure compliance through monthly audits of clinical records and follow up on any inconsistencies in clinical supervision sessions. The Quality Assurance department will conduct quarterly program review, and the Compliance department will review the plan of correction at least annually to ensure implementation. |
709.94(c) LICENSURE Project management services
709.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based on a physical plan inspection, the project failed to ensure that a telephone number was displayed conspicuously to the general public for emergency purposes.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
A notice displaying the telephone number of the program was posted at the door during the DDAP site visit on. The Program Director will monitor to ensure that this notice remains posted. The Quality Assurance department will conduct quarterly program review, and the Compliance department will review the plan of correction at least annually to ensure implementation |