INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 18, 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 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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709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records, the facility failed to ensure that annual written individual staff performance evaluations, were reviewed and signed by the employee per the facility ' s policy and procedure manual in four out of nine personnel records reviewed. The facility ' s policy and procedure manual states that the annual job performance evaluations are due at the beginning of each calendar year. Project staff indicated evaluations specifically are to be completed and signed by February 1 each year.
Employee #1 was hired on September 9, 2019 as the project director and was still in that position at the time of the inspection The annual work performance evaluation was not completed until February 28, 2024.
Employee #2 was hired on July 8, 2015 as the facility director and was still in that position at the time of the inspection. The annual work performance evaluation was not completed until February 4, 2024.
Employee #3 was hired on May 17, 2021 as a counselor and was still in that position at the time of the inspection. The annual work performance evaluation was not completed until February 2, 2024.
Employee #5 was hired on June 21, 2021 as a counselor and was still in that position at the time of the inspection. The annual work performance evaluation was not competed until February 2, 2024.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
On May 17, 2024, Division Director spoke with Program Director at Harrisburg OP to let them know the expectation is to review the annual reviews with all staff one week prior to 1/31/25. The Division Director will further review the expectation is after they are discussed with the staff, to have the staff immediately sign into their ADP to sign off on their review and write any applicable comments. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of client records, the facility failed to provide individual counseling at least twice weekly in five out of seven records reviewed.
Client #1 was admitted on October 18, 2023 and discharged on November 3, 2023. Client #1 did not have individual counseling the week of October 30, 2023 and only had one individual counseling session the week of October 23, 2023.
Client #2 was admitted on September 28, 2023 and discharged on October 12, 2023. Client #2 did not have individual counseling the week of October 2, 2023
Client #3 was admitted on December 21, 2023 and discharged on January 25, 2024. Client #3 did not individual counseling the weeks of December 25, 2023, January 15 and 22, 2024.
Client #4 was admitted on January 31, 2024 and discharged on February 20, 2024. Client #4 had only one documented individual counseling the week of February 26, 2024.
Client #9 was admitted on April 3, 2024 and still active at the time of the inspection. Client #9 had only one documented individual counseling session the week of April 8, 2024.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
On May 24th, 2024 the Program Director will conduct an in-service training during clinical team meeting regarding the frequency of individual sessions and how this should be reflected accurately on the treatment plan. Documentation of missed sessions will also be reviewed during this in-service training. Overview of the frequency of sessions as identified on comprehensive tx plan and documentation of missed sessions will be a part of the routine monthly chart audit review process conducted by Program Director. |
709.83(a)(4) LICENSURE Client records
709.83. 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:
(4) Case consultation notes.
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Observations
Based on the review of client records, the facility failed to document case consultations within the timeframe established by the facility's policy and procedure manual in four out of four applicable client records. The facility's policy and procedure manual states case consultations are completed every ninety days unless the client's treatment is less than ninety days then one is completed prior to the end of the treatment episode.
Client # 1was admitted on October 18, 2023 and discharged on November 3, 2023. A case consultation was to be completed prior to discharge if the client was only in treatment less than 90 days, there is no documentation that one was completed.
Client #2 was admitted on September 28, 2023 and was discharged on October 12, 2023. A case consultation was to be completed prior to discharge if the client was only in treatment less than 90 days, there is no documentation that one was completed.
Client #3 was admitted on December 21, 2023 and discharged on January 25, 2024. A case consultation was to be completed prior to discharge if the client was only in treatment less than 90 days, there is no documentation that one was completed.
Client #4 was admitted on January 31, 2024 and discharged on February 20, 2024. A case consultation was to be completed prior to discharge if the client was only in treatment less than 90 days, there is no documentation that one was completed.
This is a repeat citation from the May 12, 2023 licensing inspection.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Beginning May 24, 2024, the Program Director will run the Clinical Forms Audit report monthly and send out emails to all staff of case consultations coming due. The Program Director will ensure that these case consultations are completed by using CQI audit tool in the electronic health record. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of the client records, the facility failed to document a comprehensive treatment plan within guidelines established by the facility ' s policy and procedures manual in two out of six applicable records reviewed. The facility ' s policy and procedures manual states the comprehensive treatment plan must be completed within 30 days of admission.
Client #5 was admitted on August 23, 2023 and was discharged on January 19, 2024. A comprehensive treatment plan was due no later than September 23, 2023; however, it was not completed until October 16, 2023.
Client #6 was admitted on December 12, 2023 and was discharged on February 12, 2024. A comprehensive treatment plan was due no later than January 12, 2024; it was not completed until January 26, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning May 24, 2024, the Program Director will run the treatment plan analysis report on a weekly basis and send emails out to counselors of treatment plans that are due or coming due. Program Director is responsible with making sure these are completed by the counselors by completing monthly chart audits for each counselor. |
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 document treatment plan updates within the facility ' s policy and procedures manual of every thirty days in three out five applicable records reviewed.
Client #1 was admitted on January 11, 2023 and was still active at the time of the inspection. A treatment plan was completed on February 8, 2024, and the next update was due no later than April 8, 2024; however, there was no documentation that one was completed.
Client #2 was admitted on October 12, 2023 and was still active at the time of the inspection. A treatment plan was completed on February 15, 2024, and the next update was due no later than April 15, 2024; however, there was no documentation that one was completed.
Client #5 was admitted on August 23, 2023 and was discharged on January 19, 2024. A treatment plan was completed on October 16, 2023, and the next update was due no later than December 16, 2023; however, there is no documentation that one was completed.
This is a repeat citation from the March 28, 2023 and May 12, 2023 licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning May 24, 2024, the Clinical Supervisor will run the treatment plan analysis report on a weekly basis and send emails out to counselors of treatment plans that are due or coming due. Program Director is responsible with making sure these are completed by the counselors. Failure by counselors to complete these treatment plans in a timely fashion will result in disciplinary action that would start with a performance improvement plan where close monitoring of following treatment plan update policy will occur. |
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 client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in three out of five applicable records reviewed.
Client #1 was admitted on November 3, 2023 and was still active at the time of the inspection. The treatment plan dated February 8, 2024, indicated individual counseling two times a week. There was no documentation of the client receiving individual counseling the weeks of February 12 and March 11, 2024.
Client #2 was admitted on October 12, 2023 and was still active at the time of the inspection. The treatment plan dated November 14, 2023, indicated individual counseling two times a week. There was no documentation that the client received two individual counseling sessions the weeks of November 13, 20, 27, and December 4, 11, 18 and 25, 2023.
Client #4 was admitted on February 14, 2024 and was still active at the time of the inspection. The treatment plan dated March 7, 2024, indicated individual counseling sessions weekly. There was no documentation that the client received individual counseling the weeks of March 11 and 18, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning May 24th, the Program Director will conduct an in-service training during clinical team meeting regarding the frequency of individual sessions and how this should be reflected accurately on the treatment plan. Documentation of missed sessions will also be reviewed during this in-service training. Overview of the frequency of sessions as identified on comprehensive tx plan and documentation of missed sessions will be a part of the routine monthly chart audit review process conducted by Program Director. |
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 the review of client records, the facility failed to document case consultations within the timeframe established by the facility ' s policy and procedure manual in five out of six applicable client records. The facility's policy and procedure manual states case consultations are completed every ninety days unless the client ' s treatment is less than ninety then one is completed prior to the end of the treatment episode.
Client #1 was admitted on November 3, 2023 and was still active at the time of the inspection. A case consultation was due no later than February 3, 2024; however, there is no documentation that one was completed.
Client #2 was admitted on October 12, 2023 and was still active at the time of the inspection. A case consultation was due no later than January 12, 2024; however, it was not completed until February 28, 2024.
Client #3 was admitted on January 25, 2024 and discharged on January 31, 2024. A case consultation was to be completed prior to discharge if the client was only in treatment less than 90 days, there is no documentation that one was completed.
Client #5 was admitted on August 23, 2023 and discharged on January 19, 2024. A case consultation was to be completed prior to discharge if the client was only in treatment less than 90 days, there is no documentation that one was completed.
Client #7 was admitted on August 2, 2023 and discharged on March 1, 2024. A case consultation was due no later than November 2, 2023, and February 2, 2024; however, there is no documentation that case consultations occurred.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of May 24, 2024, the Program Director will run the Clinical Forms Audit report monthly and send out emails to all staff of case consultations coming due. The Program Director will ensure that these case consultations are completed through the use of the CQI tool located on the electronic health record. |
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 client records, the facility failed to provide a complete client record on an individual which includes information relative to the client's involvement with the project, including a follow up in four of four applicable records. The facility's policy and procedure manual states that a follow up is completed within seven days of discharge.
Client #3 was admitted on December 21, 2023 and discharged on January 31, 2024. A follow up was due no later than February 7, 2024; however, there is no documentation that one was completed.
Client #5 was admitted on August 23, 2023 and discharged on January 19, 2024. A follow up was due no later than January 26, 2024; however, there is no documentation that one was completed.
Client #6 was admitted on December 12, 2023 and was discharged on February 12, 2024. A follow up was due no later than February 19, 2024; however, there is no documentation that one was completed.
Client #7 was admitted on August 2, 2023 and was discharged on March 1, 2024. A follow up was due no later than March 8, 2024; however, there is no documentation that one was completed.
This is a repeat citation from the May 12, 2023 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On May 24th, Program Director will review the follow up policy and expectations with the counselors in clinical team meeting. Documentation of the follow up process will also be reviewed in this meeting. Overview of the follow up process will be part of the routine monthly chart audit review process for discharged client charts by the Program Director as well as using the follow up tool located in electronic health record that shows completion of form. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for completing and documenting treatment plan updates in the outpatient records was submitted and approved by the Department for the March 28, 2022, and May 21, 2023 annual licensing inspections. Completing and documenting treatment plan updates was again found to be a deficiency in the April 18, 2024, licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning June 17th, 2024 and occurring on a monthly basis, the Division Director will attend a CQI meeting. On the agenda of the CQI meeting is to review and present that POCs are being followed at the program level. The Division Director will report updates after completing monthly charts prior to the call, for the program as a way to monitor implementation and adherence of the POC. Any deficiencies will be reviewed with Program Director the same day of the meeting and follow through with documentation will be requested. This will continue throughout the year. |