INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 3, 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. Harrisburg Concept 90 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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709.32 (c) (6) LICENSURE Medication control
§ 709.32. Medication control.
(6) Medication errors and drug reactions shall be recorded in the client record. This may be the medical record if a separate medical record is maintained for all clients.
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Observations
Based on a review of seven client records, the facility failed to document if the clients received their medications or why they did not receive their medication in the Medication Administration Record (MAR) or Missed Medication Log in all seven client records.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
All prescribed medications, including those ordered prn will be correctly documented on the MAR. This will include indication of instances when the client refused the prn medication.
This will be addressed by the Director and the Nurse Manager via an in-service training during the upcoming Staff meeting on 5/27/21.
The Nurse will conduct daily reviews of the MARs in order to ensure accuracy. The Clinical Supervisor and/or Program Director will conduct Weekly reviews.
The Quality Assurance team will conduct quarterly reviews and the Compliance team will conduct at least annual reviews of the plan of correction to ensure compliance.
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709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of seven client records, the facility failed to document treatment plan updates within the regulatory timeframe in six client records reviewed.
Client #1 was admitted on March 5, 2021 and was still active at the time of the inspection. A treatment plan update was completed on March 16, 2021 and the next update was due no later than April 16, 2021; however, there was no update documented in the record until April 28, 2021.
Client #2 was admitted on February 17, 2021 and was still active at the time of the inspection. A treatment plan update was completed on March 3, 2021 and the next update was due no later than April 3, 2021; however, there was no update documented in the record at the time of the inspection.
Client #3 was admitted on March 18, 2021 and was still active at the time of the inspection. A treatment plan update was completed on March 26, 2021 and the next update was due no later than April 26, 2021; however, there was no update documented in the record at the time of the inspection.
Client #5 was admitted on November 2, 2020 and was discharged March 1, 2021. A treatment plan update was completed on December 28, 2020 and the next update was due no later than January 28, 2021; however, there was no update documented in the record at the time of discharge.
Client #6 was admitted on November 24, 2020 and was discharged February 12, 2021. A treatment plan update was completed on December 5, 2020 and the next update was due no later than January 5, 2021; however, there was no update documented in the record until January 18, 2021.
Client #7 was admitted on October 26, 2020 and was discharged January 26, 2021. A treatment plan update was completed on December 1, 2020 and the next update was due no later than January 1, 2021; however, there was no update documented in the record at the time of discharge.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Program Director will conduct monthly chart audits and will send email reminders to clinicians regarding upcoming documentation updates, to include Treatment Plan updates.
The clinical supervisor will conduct weekly clinical meetings to include discussions of documentation and treatment planning (as needed), and will conduct weekly clinical chart audits to ensure that treatment plans are completed in a timely manner at the appropriate intervals.
The Quality Assurance team will conduct quarterly reviews and the Compliance team will conduct at least annual reviews of the plan of correction to ensure compliance.
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709.53(a)(11) LICENSURE Follow-up information
709.53. 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 three applicable client records, the facility failed to provide a complete client record which is to include documentation of follow up information in all three client records.
Client #5 was admitted on November 2, 2020 and was discharged on March 1, 2021.
Client #6 was admitted on November 24, 2020 and was discharged on February 12, 2021
Client #7 was admitted on October 26, 2020 and was discharged on January 26, 2021.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The clinical supervisor will review upcoming discharges daily via staff meeting to ensure that follow-up information is updated, including the follow-up consent, and complete for clients who are eligible for discharge.
The administrative coordinator will document the client's date of discharge, address, and other pertinent discharge information to ensure a proper follow-up can be made within 7 days following discharge.
The Intake specialist will complete all follow-up calls within 7 days of discharge and document these calls via the EHR system.
The Quality Assurance team will conduct quarterly reviews and the Compliance team will conduct at least annual reviews of the plan of correction to ensure compliance.
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709.53(a)(12) LICENSURE Work as treatment
709.53. 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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of seven client record, the facility failed to ensure that all work completed by at the project is an integral part of the client's drug and alcohol support plan in all seven client records.
These findings were discussed with facility staff during the inspection process.
This is a repeat citation from an inspection conducted October 15, 2020.
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Plan of Correction
The Intake specialist, during the intake assessment, will list "work as treatment" on the initial treatment plan to reflect that work done by clients is therapeutic in nature and documented as an integral part of treatment.
Furthermore, work as treatment and treatment planning will be reviewed in an in-service training during staff meeting on 5/27/21 to ensure that all clinical staff include work as treatment on all concurrent treatment plan updates.
The clinical supervisor will review treatment plans weekly to ensure that any chores or other work assigned as part of treatment process will be listed as interventions in the treatment plans.
The Program Director will review treatment plans monthly to ensure that all treatment plans include work as treatment and are in conformance to this standard.
The Quality Assurance team will conduct quarterly reviews and the Compliance team will conduct at least annual reviews of the plan of correction to ensure compliance.
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