INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on October 27, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, Gaudenzia at Sunbury 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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709.93(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 ensure that two of the three applicable records contained follow up information.
Client#4 was admitted on January 10, 2020 and was discharged on June 4, 2020
Client #7 was admitted on February 3, 2020 and was discharged on May 4, 2020.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
A mandatory in-service training occurred on 11-13-20 which addressed clinical staff on treatment management procedures specific to assuring that follow up was completed within 7 days of discharge for all referrals, and within 30 days for every other type of discharge. The follow-up form has been developed in the electronic health record as of 11-6-20. The Program Director and Clinical Supervisor will review for compliance during the monthly internal CQI process. Clinical staff will be monitored monthly in regular supervisory sessions. Additionally, the Regional Quality Assurance Manager will conduct quarterly audits to ensure compliance; this audit will be documented in the quarterly CQI report. The compliance department will conduct annual reviews to ensure continued implementation of all action items on the correction action plan.
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