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 5, 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, 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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709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of seven client records, the facility failed to provide and document at least two individual counseling sessions per week for five of the seven applicable client records.
Client #1 was admitted on September 10, 2020 and was still active at the time of the inspection.
Client #2 was admitted on September 10, 2020 and was still active at the time of inspection.
Client #3 was admittedon Septebmer 22, 2020 and was still active at the time of inspection.
Client #5 was admitted on September 8, 2020 and was discharged on September 21, 2020.
Client #6 was admitted on September 4, 2020 was discharged on September September 15, 2020.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
PHP counselor will ensure that two individual sessions are occuring for each client on a weekly basis. This will be monitored by Clinical Supervisor on a weekly basis and will take effect immediately. Proper documentation of these sessions will be including in client file. |
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 two client records reviewed.
Client #9 was admitted on July 15, 2020 and was still active at the time of the inspection. A treatment plan update was completed on July 15, 2020 and the next update was due no later than September 15, 2020 ; however, the updated was not completed until September 22, 2020.
Client #10 was admitted on June 15, 2020 and was still active at the time of the inspection. A treatment plan update was completed on June 19, 2020 and the next update was due no later than August 19, 2020; however, there was not completed until September 14, 2020.
These findings were discussed with the facility staff during the inspection process.
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Plan of Correction
Primary Counselor will ensure that the treatment plan update is completed and documented within the regulatory timeframe. Clinical Supervisor will conduct monthly audits of open files to ensure these are being completed timely and documented accordingly. This is effective immediately. |
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 client records, the facility failed to provide treatment services based on the individual treatment plan in client records #9, #10, #11 and #13.
Client record #9 was admitted on June 15, 2020 and was still active at the time of the inspection. The comprehensive treatment plan dated June 19, 2020 indicated one group and one individual session weekly. The client has only received one individual session a month for July, August and September. The client record indicates no group session since August 20, 2020.
Client record #10 was admitted on July 15, 2020 and was still active at the time of the inspection. The comprehensive treatment plan dated July 15, 2020 indicated one group individual session biweekly. The client only received two individual session for the month of July 2020 and no individual session for the month of August 2020.
Client record #11 was admitted on July 13, 2020 and was still active at the time of the inspection. The comprehensive treatment plan dated July 13, 2020 indicated one group and one individual session weekly. The client's record indicated they did not receive an individual session from July 13, 2020 until August 10, 2020 and from August 31, 2020 until September 14, 2020.
Client record #13 was admitted on August 7, 2020 and was discharged on September14, 2020 . The comprehensive treatment plan dated August 7, 2020 indicated one group and one individual session weekly. The client record indicated they did not receive an individual session from August 20, 2020 until September 11, 2020.
These findings were discussed with facility staff during the inspection process
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Plan of Correction
Primary Counselor will ensure that the individual treatment plan matches that of the services being provided for each client. Clinical Supervisor will conduct monthly audits on all open charts to ensure that the individual treatment plan is being adhered to, and when necessary instruct the primary counselor to make necessary changes to remain in compliance while still meeting the clients treatment needs. This is effective immediately. |