INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 17, 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, 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 the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one of seven client records reviewed.Client #2 was admitted on December 1, 2020 and was a current client at the time of the inspection. There was documentation in the record that the client ' s funding source became effective March 1, 2021, however, a release of information form for the funding source was not documented in the client record until May 28, 2021. These findings were reviewed with project staff during the licensing process.This is a repeat citation from last year's licensure renewal inspection.
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Plan of Correction
All staff have been trained regarding the requirement to obtain an informed and voluntary consent from the client for the disclosure of information. This training occurred on July 14th 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. |
709.28 (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 the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included a dated client signature in five of seven client records reviewed.Client #1 was admitted on November 6, 2020 and was a current client at the time of the inspection. In the client records, there were five release of information forms for the primary care physician, probation officer, funding source and family that were signed and dated by a witness on October 28, 2020; however, there were no dated client signatures documented on any of the forms. Additionally, a release of information form for a recovery coach was signed and dated by a witness on March 19, 2021; however, there was no dated client signature documented on the form.Client #2 was admitted on December 1, 2020 and was a current client at the time of the inspection. In the client records, there were three release of information forms for the primary care physician, laboratory and emergency contact that were signed and dated by a witness on November 13, 2020; however, there were no dated client signatures documented on any of the forms. Additionally, a release of information form for an attorney was signed and dated by a witness on January 15, 2021; however, there was no dated client signature documented on the form.Client #3 was admitted on November 13, 2020 and was a current client at the time of the inspection. In the client records, there were two release of information forms for the primary care physician and laboratory that were signed and dated by a witness on December 24, 2020; however, there were no dated client signatures documented on the forms.Client #4 was admitted on October 13, 2020 and was discharged on January 12, 2021. In the client record, there was a release of information form for a bail agency that was signed and dated by a witness on October 13, 2020, a release of information form for a probation officer that was signed and dated by a witness on January 12, 2021 and a release of information form for judge that was signed and dated by a witness on November 16, 2020; however, there were no dated client signatures documented on the forms.Client #7 was admitted on August 26, 2020 and was discharged on April 28, 2021. In the client records, there were a release of information forms for a probation agency that was signed and dated by a witness on October 8, 2020; however, there was no dated client signature documented on the form.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Any incomplete release forms will be voided, and a new release form fully completed by June 30th 2021 including the dated signature of the client. All staff have been trained regarding the requirement to obtain a dated signature of the client. This training occurred on June 30th 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 three of seven client records reviewed.Client #2 was admitted on December 1, 2020 and was a current client at the time of the inspection. Per a comprehensive treatment and rehabilitation plan documented in the client record on December 1, 2020, the client was to receive one individual counseling session per week; however, there was no documentation in the record that the client received an individual counseling session for the weeks of December 6, 2020 through December 12, 2020, December 13, 2020 through December 19, 2020, December 20, 2020 through December 26, 2020, December 27, 2020 through January 2, 2021, February 28, 2021 through March 6, 2021, April 4, 2021 through April 10, 2021, April 25, 2021 through May 1, 2021, May 9, 2021 through May 15, 2021 and Mary 30, 2021 through June 5, 2021. Client #3 was admitted on November 13, 2020 and was a current client at the time of the inspection. Per a comprehensive treatment and rehabilitation plan documented in the client record on November 20, 2020, the client was to receive one individual counseling session per week; however, there was no documentation in the record that the client received an individual counseling session for the weeks of December 20, 2020 through December 26, 2020 and December 27, 2020 through January 2, 2021.Client #5 was admitted on November 3, 2020 and was discharged on January 13, 2021. Per a comprehensive treatment and rehabilitation plan documented in the client record on November 4, 2020, the client was to receive one individual counseling session per week; however, there was no documentation in the record that the client received an individual counseling session for the weeks of November 8, 2020 through November 14, 2020, November 15, 2020 through November 21, 2020, November 22, 2020 through November 28, 2020, December 13, 2020 through December 19, 2020 and December 20, 2020 through December 26, 2020.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
All staff have been trained regarding the requirement to provide counseling services according to the individual treatment and rehabilitation plan. This training occurred on April 28th 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. |
709.93(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 the review of client records, the project failed to document a complete client record on an individual which included follow-up information in three of four applicable client records reviewed.Client #5 was admitted on November 3, 2020 and was discharged on January 13, 2021. There was no follow-up information documented in the client record. Client #4 was admitted on October 13, 2020 and was discharged on January 12, 2021. There was no follow-up information documented in the client record. Client #6 was admitted on August 28, 2020 and was discharged on February 25, 2021. There was no follow-up information documented in the client record. These findings were reviewed with project staff during the licensing process.This is a repeat citation from last year's licensure renewal inspection.
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Plan of Correction
Follow up information will be documented for all clients post-discharge. A log of follow up will be maintained on-site. All staff have been trained regarding the requirement to document follow-up information. This training occurred on April 28 2021. The Program Director will monitor to ensure compliance through monthly audits of clinical records and the follow-up 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.
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