INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on by staff from May 26, 2021 by the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gaudeniza Inc. Fulton County 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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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of four personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that one employee received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #4 was hired as a counselor on May 18, 2019 and was due to have the communicable disease trainings no later than May 18, 2020. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Division Director contacted Gaudenzia Training Institute on June 9th, 2021 to request two trainings to be held in the Central Region. The requested trainings are: HIV/AIDS (6 hours) and TB/STD (4 hours)
Confirmation was provided that the trainings will be scheduled and held by July 31st, 2021.
Staff member who needs this training has been registered and will attend. This will be completed by July 31st, 2021.
Division Director will follow up as needed. |
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 seven client records, the facility failed to document treatment plan updates within the regulatory timeframe in four client records reviewed.
Client #1 was admitted on January 13, 2021 and was still active at the time of the inspection. A treatment plan update was completed on February 12, 2021 and the next update was due no later than April 12, 2021; however, there was no update documented in the record at the time of the inspection
Client #2 was admitted on January 29, 2021 and was still active at the time of the inspection. A treatment plan update was completed on March 1, 2021 and the next update was due no later than May 1, 2021; however, there was no update documented in the record at the time of the inspection.
Client #3 was admitted on January 11, 2021 and was still active at the time of the inspection. A treatment plan update was completed on March 9, 2021 and the next update was due no later than May 9, 2021 however, there was no update documented in the record at the time of the inspection.
Client #5 was admitted on September 24, 2020 and discharged on March 16, 2021 A treatment plan update was completed on December 15, 2020 and the next update was due no later than February 15, 2021 however, there was no update documented in the record at the time of the inspection.
These findings were discussed with facility staff during the inspection process.
This is a repeat citation from the June 26, 2019 licensing inspection.
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Plan of Correction
On June 28, 2021, Division Director will review treatment plan updates and regulatory timeframes per level of care with all counselors during weekly clinical meeting.
Beginning June 28th, 2021 and ongoing, Division Director will review treatment plan updates as part of their monthly chart audits. The Clinical Quality Manager of the Central Region will also audit charts quarterly throughout the year and look at treatment plan updates as part of their audit.
Completed chart audits will be reviewed with primary counselor and documented in supervision notes by the Division Director. Ongoing concerns will be addressed in supervision as well.
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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 seven client records, there was no documentation that the clients received counseling services according to their individual comprehensive treatment plan in four records reviewed.
Client #1 was admitted on January 13, 2021 and was still active at the time of the inspection. A treatment plan, dated February 12, 2021, indicated weekly individual sessions. The client's record of service and progress notes indicated that the client had received no individual session between April 8, 2021 and May 7, 2021.
Client #2 was admitted on January 29, 2021 and was still active at the time of the inspection. A treatment plan, dated February 12, 2021, indicated weekly individual sessions. The client's record of service and progress notes indicated that the client had received no individual session since March 24, 2021.
Client #4 was admitted on December 18, 2020 and was still active at the time of the inspection. A treatment plan, dated March 24, 2021, indicated weekly individual sessions. The client's record of service and progress notes indicated that the client had received no individual session between April 8, 2021 and May 6, 2021 and no session between March 23, 2021 and April 7, 2021.
Client #7 was admitted on October 13, 2020 and was discharged on January 19, 2021. A treatment plan, dated December 1, 2020, indicated weekly individual sessions. The client's record of service and progress notes indicated that the client had received no individual session between December 15, 2020 and January 12, 2021.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
On June 7th, 2021-Division Director conducted a clinical meeting with staff and reviewed the findings of that annual DDAP review. The Division Director discussed at length that Treatment Plans need to reflect the services offered and the services offered need to reflect the Treatment Plans. The meeting was documented by Division Director.
Ongoing, when the Division Director is signing Treatment Plans, the Division Director will compare prescribed services as indicated on the Treatment Plan with services offered for each client. If/When discrepancies occur, Division Director will reject the Treatment Plan and have the primary counselor correct it.
Should a pattern of discrepancies occur, individual supervision will be set up and provided by the Division Director with the counselor and documented to review the ongoing findings and correct them. |
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 three applicable client records, the facility failed to complete, and document follow up information in all three client records reviewed.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
On June 28th, 2021- Division Director will review Follow Up procedures and documentation with the clinical and admin staff.
Following the meeting, the counselors will dedicate time each week to complete needed follow ups for client who have discharged from the program. They will report to the Division Director their allotted time by EOB 7/2/2021 so their schedule can be marked accordingly.
Division Director will monitor completion of Follow ups through monthly chart audits. The Clinical Quality Manager will audit charts quarterly and will monitor follow ups as well.
Ongoing concerns will be addressed in supervision with the Division Director and documented. |