INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 22, 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. Outreach 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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709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one of seven client records reviewed.
Client #6 was admitted on January 21, 2021 and was discharged on April 8, 2021. A release of information form for the client ' s funding source was not documented in the client record.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Program Director and/or Clinical Supervisor will review Confidentiality and Releases of Information with all clinical staff during staff in-service by 7/30/2021. In addition, the Program Director and/or Clinical Supervisor will monitor confidential releases of information during monthly file audits and address discrepancies during staff supervisions.
The CQI department will monitor confidentiality and releases of information during quarterly CQI file audits and will report findings to the Program Director.
Person Responsible/s Program Director/Clinical Supervisor |
709.28 (c) (4) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included a dated client signature in three of seven client records reviewed.
Client #1 was admitted on January 6, 2021 and was a current client at the time of the inspection. Five release of information forms for a probation agency, emergency contact, primary care physician, laboratory and funding source were signed and dated by a witness; however, there was no dated client signature documented on the forms.
Client #5 was admitted on December 12, 2021 and was a current client at the time of the inspection. Five release of information forms for a probation agency, emergency contact, primary care physician, laboratory and funding source were signed and dated by a witness; however, there was no dated client signature documented on the forms.
Client #7 was admitted on January 22, 2021 and was discharged on May 25, 2021. Three release of information forms for a family member, laboratory and funding source were signed and dated by a witness; however, there was no dated client signature documented on the forms.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Program Director and/or Clinical Supervisor will review Confidentiality and Releases of Information with all clinical staff during staff in-service by 7/30/2021.
In addition, the program Director and /or Clinical Supervisor will monitor confidential releases of information during monthly file audits and address discrepancies during staff supervisions.
The CQI department will monitor confidentiality and releases of information during quarterly CQI file audits and will report findings to the Program Director.
All consents for release of information for both client #1 and client # 5 have been revoked and new consents will be completed for each client by 7/30/2021
Person Responsible Program Director/ Clinical Supervisor |
709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Based on the review of client records and a discharge report, the project failed to file a written unusual incident report with the Department within three business days following an unusual incident involving a death or serious injury due to trauma, suicide, medication error or unusual circumstances.
On January 7, 2021, a client was discharged from treatment due to being deceased.
On April 8, 2021, a client was discharged from treatment due to being deceased.
These findings were reviewed with project staff during the licensing process.
This is a repeat citation from last year's licensure renewal inspection.
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Plan of Correction
The Program Director has reviewed the incident report log and will forward all outstanding unusual incident reports noted on 7/16/2021
The Division Director will facilitate a staff in-service on Incident Reports and documentation with all staff by 7/30/2021
The program Director will review the incident log on a weekly basis to ensure that all reports are sent to the Department within 3 days. In addition, on a quarterly basis the CQI department will review the incident log to ensure compliance and report findings to the Program Director
Person/s Responsible Program/Division Directors |
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 the review of client records, the project failed to ensure that counseling services are provided according to the individual treatment and rehabilitation plan in six of seven client records reviewed.
Client #1 was admitted on January 6, 2021 and was a current client at the time of the inspection. A comprehensive individual treatment and rehabilitation plan, documented in the record on January 6, 2021, indicated that the client was to receive one individual counseling session per week and four group counseling sessions per week (twelve per month). There was no documentation of an individual counseling session for the weeks of May 30, 2021 through June 5, 2021. Additionally, there was no documentation for four of the twelve group counseling sessions for the month of January 2021, five of the twelve group counseling sessions for the month of February 2021 and two of the twelve group counseling sessions for the month of April 2021.
Client #2 was admitted on October 19, 2020 and was discharged on April 30, 2021. A comprehensive individual treatment and rehabilitation plan, documented in the record on January 21, 2021, indicated that the client was to receive one individual counseling session per week and four group counseling sessions per week (twelve per month). There was no documentation of an individual counseling session for the weeks of January 31, 2021 through February 6, 2021 and February 14, 2021 through February 20, 2021. Additionally, there was no documentation indicating that the client received any group counseling sessions for the months of January 2021, February 2021, March 2021 and April 2021.
Client #3 was admitted on November 3, 2020 and was discharged on May 14, 2021. A comprehensive individual treatment and rehabilitation plan, documented in the record on November 3, 2020, indicated that the client was to receive one individual counseling session per week and four group counseling sessions per week (twelve per month). There was no documentation of an individual counseling session for the weeks of November 22, 2020 through November 28, 2020, November 29, 2020 through December 5, 2020, December 6, 2020 through December 12, 2020, December 13, 2020 through December 19, 2020, December 20, 2020 through December 26, 2020 and January 3, 2021 through January 9, 2021. Additionally, there was no documentation for four of the twelve group counseling sessions for the month February 2021.
Client #4 was admitted on March 2, 2021 and was a current client at the time of the inspection. A comprehensive individual treatment and rehabilitation plan, documented in the record on March 2, 2021, indicated that the client was to receive one individual counseling session per week. There was no documentation of an individual counseling session for the weeks of March 21, 2021 through March 27, 2021, April 11, 2021 through April 17, 2021, May 16, 2021 through May 22, 2021 and May 23, 2021 through May 29, 2021.
Client #5 was admitted on December 12, 2021 and was a current client at the time of the inspection. A comprehensive individual treatment and rehabilitation plan, documented in the record on December 2, 2020, indicated that the client was to receive one individual counseling session per week. There was no documentation of an individual counseling session for the weeks of December 13, 2020 through December 19, 2020, December 27, 2020 through January 2, 2021, January 3, 2021 through February 6, 2021.
Client #6 was admitted on January 21, 2021 and was discharged on April 8, 2021. A comprehensive individual treatment and rehabilitation plan, documented in the record on January 21, 2021, indicated that the client was to receive one individual counseling session per week. There was no documentation of any individual counseling session for the months of March 2021 and April 2021.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Program Director and /or Clinical Supervisor will review Treatment Plans including the provision of services in accordance with the treatment plan. The Director will also review the "No Show" process and the proper documentation of "No Show" appointments, with all clinical staff during an in-service by 7/30/21
If an individual does not shoe for their scheduled session the Counselor will contact the individual via telephone and document the interaction with an independent note to the file.
In addition, the Program Director and /or Clinical Supervisor will monitor treatment plans and treatment plan updates during monthly file audits to ensure that the prescribed provision of service is in line with the treatment plan. The Clinical Supervisor will address discrepancies during staff supervisions.
The CQI department will monitor treatment plans and provisions of services during quarterly CQI file audits and will report findings to the Program Director.
Person/s Responsible Program Director/ Clinical Supervisor |
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 project failed to document a complete client record on an individual which included case consultation notes in three of seven client records reviewed.
Client #2 was admitted on October 19, 2020 and was discharged on April 30, 2021. There were no case consultation notes documented in the client record.
Client #3 was admitted on November 3, 2020 and was discharged on May 14, 2021. There were no case consultation notes documented in the client record.
Client #6 was admitted on January 21, 2021 and was discharged on April 8, 2021. There were no case consultation notes documented in the client record.
These findings were reviewed with project staff during the licensing process.
This is a repeat citation from last year's licensure renewal inspection.
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Plan of Correction
The Division Director will review Case Consultation with all clinical staff during an in-service by 7/30/2021.
In addition, The Clinical Supervisor will monitor Case Consultations during monthly file audits and address discrepancies during staff supervisions.
The CQI Department will monitor Case Consultations during quarterly CQI file audits and will reports findings to the Program Director.
Person/s Responsible: Division Director Clinical Supervisor. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on the review of client records, the project failed to document a complete client record on an individual which included a discharge summary in three of seven client records reviewed.
Client #2 was admitted on October 19, 2020 and was discharged on April 30, 2021. There was no discharge summary documented in the client record.
Client #6 was admitted on January 21, 2021 and was discharged on April 8, 2021. There was no discharge summary documented in the client record.
Client #7 was admitted on January 22, 2021 and was discharged on May 25, 2021.
There was no discharge summary documented in the client record.
These findings were reviewed with project staff during the licensing process.
This is a repeat citation from last year's licensure renewal inspection.
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Plan of Correction
The Division Director will review Discharge planning and documentation with all clinical staff during an in-service by 7/30/2021.
In addition, the Clinical Supervisor will monitor Discharge summaries during monthly file audits and address discrepancies during staff supervisions.
The CQI department will monitor Discharge summaries during quarterly CQI file audits and will report findings to the Program Director.
Person/s Responsible: Division Director & Clinical Supervisor |
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 the review of client records, the project failed to document a complete client record on an individual which included follow-up information in three of seven client records reviewed.
Client #2 was admitted on October 19, 2020 and was discharged on April 30, 2021. There was no follow-up information documented in the client record.
Client #3 was admitted on November 3, 2020 and was discharged on May 14, 2021. There was no follow-up information documented in the client record.
Client #7 was admitted on January 22, 2021 and was discharged on May 25, 2021.
There was no follow-up information documented in the client record.
These findings were reviewed with project staff during the licensing process.
This is a repeat citation from last year's licensure renewal inspection.
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Plan of Correction
The Division Director will review follow up information with all clinical staff during an in-service by 7/30/2021.
In addition, the Clinical Supervisor will monitor follow up information during monthly file audits and address discrepancies during staff supervisions.
The CQI department will monitor follow up information during quarterly CQI file audits and will reports findings to the Program Director.
Person/s Responsible: Division Director Clinical Supervision |