INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 6, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Common Ground 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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709.63(a)(7) LICENSURE Discharge summary
709.63. 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:
(7) Discharge summary.
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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 discharge summary in three out of four applicable records. The facility's policy and procedures manual states that a discharge summary is completed within seven days of discharge.
Client #3 was admitted June 3, 2024 and was discharged on June 6, 2024. A discharge summary was due no later than June 13, 2024; however, there was no documentation that one was completed.
Client #4 was admitted on March 14, 2025 and was discharged on March 15, 2025. A discharge summary was due no later than March 22, 2025; however, there was no documentation that one was completed.
Client #6 was admitted on October 19, 2024 and was discharged on October 21, 2024. A discharge summary was due no later than October 28, 2024; however, there was no documentation that one was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.63(a)(7) Discharge summary
(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: (7) Discharge summary.
A discharge summary will be completed no later than 72 hours from the time of discharge for all discharged individuals.
Staff will be reminded of this requirement, including review of our documentation workflow and the Discharge Summary form to utilize in the record. This will be conducted in an all-staff meeting facilitated by the Clinical Supervisor and Program Director no later than 6/26/25.
This will be monitored during regular monthly reviews of a sample of charts conducted by the Clinical Supervisor and Program Director. Any issues noted will be documented in a clinical supervision session with the clinician and corrected within 48 hours.
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709.63(a)(8) LICENSURE Follow-up Information
709.63. 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) Follow-up information.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include follow-up information in four out of four applicable discharged records reviewed. The facility ' s policy and procedures manual states that a follow up contact is completed within seven days of discharge.
Client #3 was admitted June 3, 2024 and was discharged on June 6, 2024. A follow up contact was due no later than June 13, 2024; however, the follow up contact wasn ' t completed until June 21, 2024.
Client #4 was admitted on March 14, 2025 and was discharged on March 15, 2025. A follow up contact was due no later than March 22, 2025; however, the follow up contact wasn ' t completed until March 24, 2025.
Client #5 was admitted on August 15, 2024 and discharged on August 20, 2024. A follow up contact was due no later than August 27, 2024; however, the follow up contact wasn ' t completed until September 3, 2024.
Client #6 was admitted on October 19, 2024 and was discharged on October 21, 2024. A follow up contact was due no later than October 28, 2024; however, there is no documentation that a follow up occurred.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.63(a)(8) Follow-up Information
(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) Follow-up information.
A Follow-Up Contact note will be completed no later than 7 days of the referral appointment or 30 days of discharge for all discharged individuals.
A follow up contact will be completed and documented with in 7 days for all AMA ? Non complaint Discharges
Staff will be reminded of this requirement, including review of our documentation workflow and the Follow-Up Contact form to utilize in the record. This will be conducted in an all-staff meeting facilitated by the Clinical Supervisor and Program Director no later than 6/26/25.
This will be monitored during regular monthly reviews of a sample of charts conducted by the Clinical Supervisor and Program Director. Any issues noted will be documented in a clinical supervision session with the clinician and corrected within 48 hours.
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