INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 24, 2023, 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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705.7 (b) (6) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(6) Store all food items off the floor.
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Observations
Based on a physical plant inspection, the facility failed to ensure that all food was stored off the floor.
In the room labeled " Cook " , that consisted of the cook ' s office and food storage, there was a large bag of onions and boxes of food found sitting on the floor.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All staff will be educated on proper food storage procedures on 6/15/23. This will be documented via a sign-in sheet.
More storage shelving has been added so that no food items will be stored on the floor as of 6/1/23.
This will be monitored on a regular basis during monthly walk-throughs by the Program Director, and during quarterly physical plant reviews conducted by the QA Manager. Any issues noted will be reported to the Program Director to be addressed immediately
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705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the fire drill logs, the facility failed to maintain a written fire drill record including whether the fire alarm or smoke detector was operative from April 2022 through March 2023.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Moving forward, a new tracking sheet has been posted in the RSP office for each shift to be completed monthly. This includes a section to ensure that fire alarms and smoke detectors are operational. The Program Director will review this documentation on a monthly basis to ensure that it is completed.
Moving forward, during fire drills, the fire alarm company will be notified of upcoming fire drills so that the system can be unarmed, and the alarms can be sounded manually.
The QA Manager will review Fire Drill logs on a quarterly basis to ensure that this is being completed. Any issues noted will be reported to the Program Director to be addressed immediately.
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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 a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in one of seven client records reviewed.
Client #6 was admitted on September 29, 2022 and discharged on December 1, 2022. There was not a documented informed and voluntary consent from the client for their funder; however, the facility acknowledged billing had occurred.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will review confidentiality regulations with staff to include the need for billing/funding consents in an all-staff meeting on 6/15/23. This will be documented in the meeting minutes.
The Program Director or Clinical Supervisor will audit charts weekly to ensure that all needed release of information forms are completed. Audits will be reviewed with staff weekly and documented in a supervision note. This process will begin the week of 6/19/23. All missing documentation will be completed within 48 hours.
The QA Manager will audit a sample of charts on a quarterly basis to ensure that this is being completed per regulations. Any issues noted will be reported to the Clinical Supervisor and Program Director to be addressed immediately. |
709.51(b)(3)(i) LICENSURE Medical histories
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on the review of client records, the facility failed to document a medical history within 72 hours of admission, per the facility ' s policy manual, in four out of seven records.
Client #2 was admitted on March 31, 2023 and was still active at the time of the inspection. A medical history was due no later than April 3, 2022; however, was completed on April 4, 2023.
Client # 3 was admitted on March 30, 2023 and was still active at the time of the inspection. A medical history was due no later than April 2, 2023; however, was completed on April 4, 2023.
Client # 5 was admitted on March 15, 2023 and was discharged on May 8, 2023. A medical history was due no later than, March 18, 2023; however, was completed on March 21, 2023.
Client # 6 was admitted on September 29, 2022 and discharged on December 1, 2022. A medical history was due no later than October 1, 2022; however, it was completed on October 5, 2022.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Moving forward if the nurse is on vacation- a telehealth assessment will be set up with nursing staff from Common Ground to complete nursing assessment. This will begin the week of 6/12/23.
Program Director will audit medical charts weekly and review with facility nurse. This will be documented in a supervision note starting the week of 6/12/23.
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709.51(b)(3)(ii) LICENSURE Drug & Alcohol History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on the review of client records, the facility failed to document a drug and alcohol history within 72 hours of admission, per the facility ' s policy manual, in four out of seven records.
Client #2 was admitted on March 31, 2023 and was still active at the time of the inspection. A drug and alcohol history was due no later than April 3, 2022; however, was completed on April 4, 2023.
Client # 3 was admitted on March 30, 2023 and was still active at the time of the inspection. A drug and alcohol history was due no later than April 2, 2023; however, was completed on April 4, 2023.
Client # 5 was admitted on March 15, 2023 and was discharged on May 8, 2023. A drug and alcohol history was due no later than, March 18, 2023; however, was completed on March 21, 2023.
Client # 6 was admitted on September 29, 2022 and discharged on December 1, 2022. A drug and alcohol history was due no later than October 1, 2022; however, it was completed on October 5, 2022.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Program Director will review the policy and time frame of biopsychosocial completion with staff during all staff meeting 6/15.
Program Director or Clinical Supervisor will audit charts weekly and review with staff on a weekly bases. This will be documented in a supervision note beginning the week of 6/19/23. All missing documentation will be completed within 48 hours.
The QA Manager will audit a sample of charts on a quarterly basis to ensure that this is being completed per regulations. Any issues noted will be reported to the Clinical Supervisor and Program Director to be addressed immediately.
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709.51(b)(3)(iii) LICENSURE Personal History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on the review of client records, the facility failed to document a personal history within 72 hours of admission, per the facility ' s policy manual, in four out of seven records.
Client #2 was admitted on March 31, 2023 and was still active at the time of the inspection. A personal history was due no later than April 3, 2022; however, was completed on April 4, 2023.
Client # 3 was admitted on March 30, 2023 and was still active at the time of the inspection. A personal history was due no later than April 2, 2023; however, was completed on April 4, 2023.
Client # 5 was admitted on March 15, 2023 and was discharged on May 8, 2023. A personal history was due no later than, March 18, 2023; however, was completed on March 21, 2023.
Client # 6 was admitted on September 29, 2022 and discharged on December 1, 2022. A personal history was due no later than October 1, 2022; however, it was completed on October 5, 2022.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Moving forward, if the nurse is on vacation, a telehealth assessment will be set up with nursing staff from another Gaudenzia program to complete the nursing assessment. This will begin the week of 6/19/23.
The Program Director will audit medical charts weekly and review with the facility nurse. This will be documented in a supervision note starting the week of 6/19/23.
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709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to document a psychosocial evaluation within 72 hours of admission, per the facility ' s policy manual, in five out of seven records.
Client #1 was admitted on April 11, 2023 and was still active at the time of the inspection. A psychosocial evaluation was due no later than April 14, 2022; however, was completed on April 20, 2023.
Client #2 was admitted on March 31, 2023 and was still active at the time of the inspection. A psychosocial evaluation was due no later than April 3, 2023; however, was completed on April 4, 2023.
Client # 3 was admitted on March 30, 2023 and was still active at the time of the inspection. A psychosocial evaluation was due no later than April 2, 2023; however, was completed on April 9, 2023.
Client #4 was admitted on March 30, 2023 and was still active at the time of the inspection. A psychosocial evaluation was due no later than April 2, 2023; however, there was no documentation that one was completed.
Client # 6 was admitted on September 29, 2022 and discharged on December 1, 2022. A psychosocial evaluation was due no later than October 1, 2022; however, there was no documentation that one was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will review the policy and time frame of bio completion with staff during all staff meeting 6/15. This will be documented in the meeting minutes.
Program Director or Clinical Supervisor will audit charts weekly and review with staff on a weekly bases. This will be documented in a supervision note beginning the week of 6/19/23. All missing documentation will be completed within 48 hours
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709.51(b)(7) LICENSURE Preliminary Tx. Plan.
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document a preliminary treatment plan within five days of admission, per the facility ' s policy manual, in three out of seven records.
Client# 2 was admitted on March 31, 2023 and was still active at the time of the inspection. There was no documentation of a preliminary treatment plan at the time of the inspection.
Client #3 was admitted on March 30, 2023 and still active at the time of the inspection. The preliminary treatment plan was due on April 4, 2023; however, it was not completed until April 10, 2023.
Client #4 was admitted on March 30, 2023 and still active at the time of the inspection. The preliminary treatment plan was due no later than April 4, 2023; however, it was not completed until April 13, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
: Program Director will review Tx plan completion and time frames during an all staff meeting 6/15/23. This will be documented in the meeting minutes.
Program Director or Clinical Supervisor will audit charts weekly and review with staff on a weekly bases starting the week of 6/19/23. This will be documented in a supervision note. All missing documentation will be completed within 48 hours.
Deputy Director will hold an in-service training with clinical staff to address Tx plan completion to include, ASAM alignment, time frames, and SMART goals by 6/30/23.
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709.53(a)(9) LICENSURE Aftercare plans
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:
(9) Aftercare plan, if applicable.
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Observations
Based on the review of client records, the facility failed to document an aftercare plan in four out of seven records reviewed. The facility ' s policy manual indicates the aftercare plan begins within 72 hours of admission.
Client #3 was admitted on March 30, 2023 and was still active at the time of the inspection. There was no documentation that an aftercare plan was started.
Client # 4 was admitted on March 30, 2023 and was still active at the time of the inspection. There was no documentation that an aftercare plan was started.
Client # 5 was admitted on March 15, 2023 and discharged on May 8, 2023. There was documentation that an aftercare plan was developed.
Client # 7 was admitted on June 1, 2022 and discharged on July 19, 2022. There was no documentation that an aftercare plan was started.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
: Program Director reviewed aftercare planning with staff 6/1/23.
Program Director or Clinical Supervisor will audit charts weekly and review with staff beginning week of 6/19/23. The QA Manager will audit a sample of charts on a quarterly basis to ensure that this is being completed per regulations. Any issues noted will be reported to the Clinical Supervisor and Program Director to be addressed immediately |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based on the review of client records, the facility failed to document a discharge summary in two out of three applicable records reviewed.
Client # 5 was admitted on March 15, 2023 and discharged on May 8, 2023.
Client # 7 was admitted on June 1, 2022 and discharged on July 19, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director reviewed discharge summary completion with staff 6/1/23.
Program Director or Clinical Supervisor will audit charts weekly and review with staff beginning week of 6/19/23. This will be documented in a supervision note. All missing documentation will be completed within 48 hours.
The QA Manager will audit a sample of charts on a quarterly basis to ensure that this is being completed per regulations. Any issues noted will be reported to the Clinical Supervisor and Program Director to be addressed immediately. |
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 the review of client records, the facility failed to document follow up information within seven days of discharge if referred to another program or service and 30 days if the client declines a referral to another program or service, per facility policy, in two out of three applicable client records.
Client #5 was admitted on March 15, 2023 and was discharged on May 8, 2023. There was no documentation that any follow up was completed.
Client#7 was admitted on June 1, 2022 and discharged on July 19, 2022. There was no documentation that any follow up was completed.
This is a repeat citation from the May 5, 2022 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director reviewed follow up policy and procedures with staff 6/1/23.
Program Director or Clinical Supervisor will audit discharge charts weekly and review with staff beginning week of 6/19/23. This will be documented in a supervision note. All missing documentation will be completed within 48 hours.
The QA Manager will audit a sample of charts on a quarterly basis to ensure that this is being completed per regulations. Any issues noted will be reported to the Clinical Supervisor and Program Director to be addressed immediately.
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