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 1, 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, 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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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
The project failed to document at least 12 clock hours of annual training for the facility director, based on a review of personnel records.
Employee #2 was hired on February 6, 2017 and was still employed at the time of the inspection. The personnel record only documented 4.5 clock hours of annual training for the facility's January 2019 through December 2019 training year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All personnel will receive the correct number of hours of annual training. The Division Director will ensure that the facility Clinical Supervisor/Division Director completes the required amount of training by developing an annual training plan with the Clinical Supervisor/Division Director, reviewing the plan at least monthly in supervision sessions with the Clinical Supervisor/Division Diretor, and assisting in the scheduling of trainings as needed. In addition, the Compliance Department will conduct annual reviews of of Corrective Action Plans to ensure compliance.. |
704.11(e)(2) LICENSURE Annual Trng Req-Clin Sup
704.11. Staff development program.
(e) Training requirements for clinical supervisors.
(2) Each clinical supervisor shall complete at least 12 clock hours of training annually in areas such as:
(i) Supervision and evaluation.
(ii) Counseling techniques.
(iii) Substance abuse trends and treatment methodologies in the field of addiction.
(iv) Confidentiality.
(v) Codependency/Adult Children of Alcoholics (ACOA) issues.
(vi) Ethics.
(vii) Interaction of addiction and mental illness.
(viii) Cultural awareness.
(ix) Sexual harassment.
(x) Developmental psychology.
(xi) Relapse prevention.
(xii) Disease of addiction.
(xiii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
The project failed to document at least 12 clock hours of annual training for a clinical supervisor, based on a review of personnel records.
Employee #3 was hired on August 10, 2010 and was still employed at the time of the inspection. The personnel record only documented 5.5 clock hours of annual training for the facility's January 2019 through December 2019 training year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All personnel will receive the correct number of hours of annual training. The Division Director/Clinical Supervisor will ensure that the Clinical Supervisor completes the required amount of training by developing an annual training plan with the Clinical Supervisor, reviewing the plan at least monthly in supervision sessions with the Clinical Supervisor, and assisting in the scheduling of trainings as needed. In addition, the compliance Department will conduct annual reviews of Corrective Action Plans to ensure compliance. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
The project failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in two of seven client records reviewed.
Client #2 was admitted on November 8, 2019 and was discharged on March 2, 2020 A release of information form to a funding source was signed and dated by the client on February 13, 2020 which allowed for the release of psychological and psychiatric evaluations, treatment plans and mental health records, all of which exceeds the limits established by 4 Pa. Code 255.5. Additionally, a release of information form to a supplementary funding source was signed and dated by the client on February 13, 2020 which allowed for the treatment plans.
Client #6 was admitted on July 29, 2020 and was discharged on September 17, 2020. A release of information form to a funding source was signed and dated by the client on July 8, 2020, which allowed for the release of psychological and psychiatric evaluations, treatment plans, case consults, mental health records, physical and medical records, discharge summary, progress notes, medication records, and assessments, all of which exceeds the limits established by 4 Pa. Code 255.5.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All releases of information will be kept within the limits established by 4 PA Code 255.5 (b). All clinical staff will be trained by the Clinical Supervisor/Division Director in an in-service training on 11/19/2020 regarding these limits as well as the correct use of the release of information form in the electronic health record. The Quality Assurance department will conduct at least quarterly reviews of the program in order to ensure compliance. The findings of these audits will be reviewed in regular CQI meetings following the audits. The compliance department will conduct at least annual reviews to ensure compliance with corrective action plans. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
The project failed to ensure that a copy of a client consent to release information form was offered to the client in three of seven client records reviewed.
Client #2 was admitted on November 8, 2019 and was discharged on March 2, 2020. A release of information form to a recovery house was signed and dated by the client on February 13, 2020. There was no documentation that this client was offered a copy of the consent form.
Client #4 was admitted on February 18, 2020 and was discharged on June 24, 2020. A release of information form to a funding source was signed and dated by the client on March 3, 2020. There was no documentation that this client was offered a copy of the consent form.
Client #5 was admitted on February 25, 2020 and was an active client at the time of the inspection. A release of information form to a probation agency was signed and dated by the client on April 6, 2020. There was no documentation that this client was offered a copy of the consent form.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All active client charts have been reviewed and updated. All consents to release information will be offered to the client and the form will be completely filled out to indicate such. All clinical staff will be trained by the Clinical Supervisor/Program Director/Division Director in an in-service training on 11/19/2020 regarding these requirements and the use of the release of information forms in the electronic health record. The Clinical Supervisor/Program Director/Division Director will conduct weekly audits to ensure all consent forms are being offered to the clients. The Quality Assurance department will conduct at least quarterly reviews of the program in order to ensure compliance. The findings of these audits will be reviewed in regular CQI meetings following the audits. The compliance department will conduct at least annual reviews to ensure compliance with corrective action plans. |
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
The project failed to file a written unusual incident report with the Department within 3 business days following an unusual incident involving a death or serious injury due to trauma, suicide, medication error or unusual circumstances. Based on a client record review, Client #4 was discharged due to being deceased; however, there was no documentation provided that the Department was notified within 3 business days.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A written unusual incident report will be filed with the Department within 3 business days following an unusual incident involving a death or serious injury due to trauma, suicide, medication error or unusual circumstances. All staff will be trained by the Clinical Supervisor/Division Director in an in-service training on 11/20/2020 regarding these requirements and the Gaudenzia policies related to Incident Reporting. The Quality Assurance department will conduct at least quarterly reviews of the program in order to ensure compliance. The findings of theses audits will be reviewed in regular CQI meetings following the audits. The Compliance department will conduct at least annual reviews to ensure compliance with corrective action plans. |
709.92(a)(1) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
The facility failed to document an individual treatment and rehabilitation plan that included short and long-term goals for treatment as formulated by both staff and client in two of seven client records reviewed.
Client #4 was admitted on February 18, 2020 and was discharged on June 24, 2020. There was a comprehensive treatment plan developed on March 3, 2020; however, there was no short or long-term goals documented on the treatment plan.
Client #5 was admitted on February 25, 2020 and was a current client at the time of the inspection. There was a comprehensive treatment plan developed on March 2, 2020; however, there was no short or long-term goals documented on the treatment plan.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All charts of active clients have been reviewed and updated.
Going forward the /Facility Director/Division Director and Clinical Supervisor will monitor closely clinical charts to ensure that counselors are following the procedure on the development of short and long-term goals in collaboration with the client.Procedures will be reviewed with counselor(s)during weekly staff meetings to ensure counselor is following procedures. Program Director/Division Director & Clinical Supervisor will monitor charts to ensure that documentation (treatment plans) has indicated short and long term goals, frequency, supportive services and done timely according to the policy. Included but not limited to the comprehensive treatment plan(s) that are due 30 days following the preliminary plan,that is completed on the initial session.
Clinical Supervisor and/or Program Director/ Division Director to assure that the charts have treatment plans as required from the initial session to the current date of active members. The charts will be audited to assure that the comprehensive treatment plan has ALL information needed including short and long term goals, the frequencies, signatures and done within timeframe required. |
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
The facility failed to document a complete client record on the individual's involvement with the project, which is to include case consultation notes, in three of seven client records reviewed.
Client #1 was admitted September 10, 2019 and was discharged on January 28, 2020. There were no case consultations documented in the client's record.
Client #2 was admitted November 8, 2019 and was discharged on March 2, 2020. There were no case consultations documented in the client's record.
Client #4 was admitted on February 18, 2020 and was discharged on June 24, 2020. There were no case consultations documented in the client's record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A complete client record will be maintained for all individuals, which includes case consultation notes. All clinical staff will be trained by the Clinical Supervisor/Division Director in an in-service training on 11/19/2020 regarding these requirements and the use of the Case Consultation Note in the electronic health record. The Quality Assurance department will conduct at least quarterly reviews of the program in order to ensure compliance. The findings of these audits will be reviewed in regular CQI meetings following the audits. The Compliance department will conduct at least annual reviews to ensure compliance with corrective action plans. |
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
The facility failed to document a complete client record on the individual's involvement with the project, which is to include a discharge summary, in two of seven client records reviewed.
Client #2 was admitted November 8, 2019 and was discharged on March 2, 2020. There was no discharge summary documented in the client's record.
Client #4 was admitted on February 18, 2020 and was discharged on June 24, 2020. There was no discharge summary documented in the client's record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A complete client record will be maintained for all individuals, which includes a discharge summary for all discharged clients. All clinical staff will be trained by the Clinical Supervisor/Division Director in an in-service training on 11/19/2020 regarding these requirements and the use of the Discharge Summary in the electronic health record. This form has bee recently revised and integrated into our Continuing Care/Transition Plan to help ensure that all required documentation is completed at discharge. The Quality Assurance department will conduct at least quarterly reviews of the program in order to ensure compliance. The findings of these audits will be reviewed in regular CQI meetings following the audits. The Compliance department will conduct at least annual reviews to ensure compliance with corrective action plans. |
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
The facility failed to document a complete client record on the individual's involvement with the project, which is to include follow-up information, in three of seven client records reviewed.
Client #1 was admitted September 10, 2019 and was discharged on January 28, 2020. There was no follow-up information documented in the client's record as of the date of the inspection.
Client #3 was admitted November 21, 2019 and was discharged on August 20, 2020. There was no follow-up information documented in the client's record as of the date of the inspection.
Client #7 was admitted on May 11, 2020 and was discharged on July 16, 2020. There was no follow-up information documented in the client's record as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A complete client record will be maintained for all individuals, which includes follow-up information for all discharged clients. All clinical staff will be trained by the Clinical Supervisor/Division Director in an in-service training on 11/19/2020 regarding these requirements and the use of the newly developed Follow-up document in the electronic health record. This electronic form will replace our previous system of documenting this in a paper log binder. The Quality Assurance department will conduct at least quarterly reviews of the program in order to ensure compliance. The findings of these audits will be reviewed in regular CQI meetings following the audits. The Compliance department will conduct at least annual reviews to ensure compliance with corrective action plans. |