INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 12, 2022 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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709.92(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 regulatory timeframe in two out of two client records reviewed.
Client #1 was admitted on October 21, 2021 and was discharged on February 7, 2022. A treatment plan was completed on November 6, 2021 and the treatment plan update was due no later than January 6, 2022; however, the treatment plan update was completed on January 10, 2022.
Client #2 was admitted on January 24, 2022 and was discharged on April 12, 2022. A treatment plan was completed on January 24, 2022 and the treatment plan update was due no later than March 24, 2022; however, there was no update documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervision sessions will be held with each clinician no later than 10/14/22 to address treatment management procedures specific to the treatment plan update process.
All staff will be directed to update treatment plans at least every 30 days for IOP and 60 days for OP. Should the client not attend the scheduled session to develop treatment plans as scheduled, clinical staff will proceed to update the plan as appropriate and document that the plan will be reviewed with the client during the next attended session and updated as needed at that time.
The Clinical Supervisor and Division Director will review treatment plans for compliance during monthly audits. This will be reviewed with Clinical staff in documented regular supervisory sessions. Any outstanding items will be corrected/completed within 48 hours.
The Quality Assurance department will complete at least quarterly reviews, to include audits of treatment plan updates for completion. Any issues noted in this area will result in the development of a performance improvement plan.
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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 conduct a follow up in one out of two applicable records reviewed.
Client #2 was admitted on January 24, 2022 and was discharged on April 12, 2022. The client record did not contain documentation of a follow up after discharge.
The finding was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Supervision sessions will be held with the Executive Assistant no later than 10/14/22 to review discharge documentation requirements to include discussion regarding required timeframes for Follow up Contacts for referrals and others included in Gaudenzia OP policy and procedures.
The Executive Assistant will run the Details of Discharge by Program Report weekly and then again monthly to ensure that all discharged individuals have been noted. Executive Assistant will compare reports to spreadsheets. Executive Assistant will inform Supervisor via email of contacts made.
The Clinical Supervisor and Division Director will perform monthly audits of discharged client charts to ensure that Follow Up Contact Notes are entered to client charts in a timely manner.
The Quality Assurance department will complete at least quarterly reviews, to include audits of Follow-Up Contact notes. Any issues noted in this area will result in the development of a performance improvement plan.
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