INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 15, 2022, 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of six personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that one employee received the minimum of at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #4 was hired as a counselor on April 26, 2021 and was due to have the communicable disease trainings no later than April 26, 2022. However, the training was not completed until May 27, 2022.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
704.11 (c) (1) Licensure ?Mandatory Communicable Disease Training
Employee #4 completed training of TB/STI/Hepatitis on 5/27/2022, training of HIV completed 9/14/21, 9/15/21
The Clinical Supervisor will review employee training records quarterly via our electronic training system as part of the individual training plan implementation process.
The Division Director will review individual training plans with the Clinical Supervisor during documented supervision sessions on a quarterly basis.
The Clinical Supervisor and Division Director have signed up to receive alerts when upcoming DDAP trainings become available.
The Clinical Supervisor will collaborate with counselors to ensure prompt enrollment into required training sessions. This will be documented in supervision notes.
he CQI Manager will review all open Plans of Correction during the quarterly review process and will advise program management of identified deficiencies.
Target Date: 7/15/22
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709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a review of administrative documents submitted, the project failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
The project's last annual financial audit was for the years ending June 30, 2020 and 2019.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
709.25 Fiscal Management
The Annual Financial Audit for the most recent fiscal year (FY 2020 ? 2021) was not completed in a timely manner due to delays on the part of the independent certified public accounting firm.
Among these delays were the application of new standards regarding the review of all leased properties (to include all real estate, business machines, and vehicles). This was a very laborious process that will not need to be repeated in the future.
Gaudenzia will obtain a completed financial audit from the independent certified public accounting firm on or before September 30th of 2022.
In order to help ensure that these delays do not occur in the future, the reorganized Fiscal department will begin preparation of all possible documents required for the audit as early as possible in the year.
Leadership in this department reviewed the regulations in DDAP 709.25 on 4/26/22 in order to ensure that all understand the importance of timely completion of the Financial Audit.
The Chief Financial Officer will oversee this process.
Target Date: 9/30/22
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709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records, the facility failed to ensure that personnel records contained a reviewed and signed annual written staff performance evaluation in two of four applicable records.
Employee # 2 was hired as a clinical supervisor on August 10, 2010 and is current in that position. The annual written staff performance evaluation for the 2021 calendar year period was not signed by the employee as of the date of the inspection.
Employee # 3 was hired as a counselor on June 27, 1997 and is current in that position. The annual written staff performance evaluation for the 2021 calendar year period was not signed by the employee 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
. 709.26 (b) (3) Personnel Management
The Clinical Supervisor will obtain current employees' signatures on their 2021 annual performance evaluation forms. This will occur no later than 7/15/22.
The Clinical Supervisor will ensure that employees electronically sign performance evaluation forms on the date of review with the employee. If necessary, the Clinical Supervisor will also ensure that any paper copies of the evaluation form are signed by the employee and a copy uploaded to their file. The Program Director will do the same for the Clinical Supervisor, and the Division Director will do the same for the Program Director.
By the end of the 3rd quarter of each fiscal year, the Division Director will meet with the Clinical Supervisor during a documented supervision session to ensure that all evaluation forms have been completed and signed.
Target Date: 7/15/22
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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 thirteen client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in eight records reviewed.
Client #1 was admitted to the Outpatient activity on March 3, 2022 and was discharged on June 7, 2022. The record contained documentation that personally identifying information was sent to an outside treatment provider, however, the record contained no consent to release information form signed by the client.
Client #7 was admitted to the Outpatient Activity on April 19, 2022 and was active at the time of the inspection. The record did not contain a client signed consent to release information form to the funding source, however, the record contained evidence that billing occurred during that time period.
Client #8 was admitted to the Intake, Evaluation, and Referral activity on July 1, 2021. The record contained documentation that personally identifying information was released to the Department of Human Services on July 1, 2021, with no client signed consent to release information form signed by the client.
Client #9 was admitted to the Intake, Evaluation, and Referral activity on September 3, 2021. The record contained documentation that personally identifying information was released to the Department of Human Services on September 3, 2021, with no client signed consent to release information form signed by the client. Additionally, the record contained documentation that personally identifying information was sent to an outside treatment provider on September 3, 2021, however, the record contained no consent to release information form signed by the client.
Client #10 was admitted to the Intake, Evaluation, and Referral activity on October 15, 2021. the record contained documentation that personally identifying information was released to the Department of Human Services on October 15, 2021, with no client signed consent to release information form signed by the client.
Client #11 was admitted to the Intake, Evaluation, and Referral activity on November 1, 2021. The record contained documentation that personally identifying information was sent to an outside treatment provider on November 1, 2021, however, the record contained no consent to release information form signed by the client.
Client #12 was admitted to the Intake, Evaluation, and Referral activity on January 14, 2022. The record contained documentation that personally identifying information was sent to an outside treatment provider on January 14, 2022, however, the record contained no consent to release information form signed by the client.
Client #13 was admitted to the Intake, Evaluation, and Referral activity on March 2, 2022. The record contained documentation that personally identifying information was sent to an outside treatment provider on March 2, 2022, however, the record contained no consent to release information form signed by the client.
This is a repeat citation from the June 22, 2021 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.28 (c) Confidentiality ? (repeat)
Issues: PII was sent w/o signed consent to funding source, outside treatment center [upon discharge], DHS [for Promise billing purposes]
The Clinical Supervisor will ensure that the appropriate consents are added to the electronic health records of Client #7. This will be completed no later than 7/15/22. This will be completed no later than 7/15/22.
Upon admission, Counselors will obtain signed consents for all newly admitted clients for the Department of Human Services to prevent the disclosure of personally identifying information at Intake, Evaluation, and Referral.
Counselors will ensure that a signed consent form has been obtained for any outside treatment center.
The Clinical Supervisor will hold a staff meeting no later than 7/10/22 to inform all clinicians of the requirement to obtain consents for DHS for all clients.
For all currently enrolled clients, Counselors will obtain a signed consent for DHS at the client's next visit. This will be completed no later than 7/15/22.
The Clinical Supervisor will conduct monthly clinical chart audits using the standard Gaudenzia audit tools which include a review of completed consents. Any consent forms found to be missing or incomplete will be brought to the attention of the clinician, documented in a supervision note, and corrected within 72 hours.
The CQI Manager will perform quarterly quantitative and qualitative clinical chart audits to include a review of signed consent forms.
7/15/22
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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 a review of seven client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include case consultation notes in three of five applicable records reviewed.
Client #4 was admitted on November 11, 2021 and was discharged on March 18, 2022. The client record did not contain documentation of case consultation notes.
Client #5 was admitted on December 23, 2021 and was active at the time of the inspection. The client record did not contain documentation of case consultation notes.
Client #6 was admitted on January 18, 2022 and was active at the time of the inspection. The client record did not contain documentation of case consultation notes.
This is a repeat citation from the June 22, 2021 and October 1, 2020 annual licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
5. 709.93 (a)(8) Licensure: Client records ? Case Consultations (repeat)
Client 4: Discharged
Client #5:completed 6/16/22
Client #6:completed 7/13/22
This area is being addressed in a Performance Improvement Plan (PIP) which was created on 6/1/22 as a result of a regular quarterly review conducted by the Quality Assurance department. The following action items are a part of this PIP, already in progress.
Counselors will begin using a reminder system in the electronic health record system to track client case management activities.
The Clinical Supervisor will run the Clinical Notes Audit Report weekly to keep abreast of upcoming case consultations and will run the Forms Audit report once per month and send emails to counselors whose clients have upcoming case consults.
Counselors will route completed Case Consultations to all participating parties for signature after which the Clinical Supervisor will sign and approve.
The Clinical Supervisor will perform monthly admission, discharge, and clinical chart audits using the standard Gaudenzia audit tools.
The Division Director will perform monthly quantitative clinical chart audits using the standard Gaudenzia audit tools.
The CQI Manager will perform quarterly quantitative and qualitative clinical chart audits to include a review of timeliness of case consultation completion.
Target: 7/15/22
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709.94(e) LICENSURE Project management services
709.94. Project management services.
(e) The project shall develop a written client follow-up policy.
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Observations
Based on a review of client records, the facility failed to follow their written client follow-up policy in two of four applicable records reviewed.
Client #1 was admitted on March 3, 2022 and discharged on June 7, 2022. The facility failed to follow-up with the referral treatment provider within seven days of the client ' s discharge.
Client #3 was admitted on August 13, 2021 and was discharged on February 15, 2022. The facility failed to follow-up with the client within 30 days of discharge, as follow-up was not completed until June 6, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.94 (c) Licensure: Project Management Services ? Follow Up
Issue: Client 1: (referral_ no follow up within 7 days; Client 3: (ASA) - due w/in 30 days of 2/15/22- contacted 6/6/22
Client 1:note completed 7/12/22
Client 3:note completed 6/6/22(late)
This area is being addressed in a Performance Improvement Plan (PIP) which was created on 6/1/22 as a result of a regular quarterly review conducted by the Quality Assurance department. The following action items are a part of this PIP, already in progress.
The Clinical Supervisor will review the Census and Caseload Management Sheets weekly and distribute them to Counselors. The program aims to discharge non-compliant clients within 3 weeks.
The Clinical Supervisor will also review the Detail Discharge Report with staff to ensure that discharges are accurately recorded, and that follow-ups are conducted.
All Counselors have received a list explaining discharge types as of 6/1/22.
The Clinical Supervisor and Corp. OP Director will conduct training on the new workflows for the direct admit initiative no later than 7/15/22.
The CQI Manager will review the census weekly and provide an account to the Clinical Supervisor of clients who have not attended session within 3 weeks. The CQI Manager will evaluate the effectiveness of this action step at the next quarterly review by 9/30/22.
Target: 9/30/22
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709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction to ensure a complete client record included information relative to the client's involvement with the project to include case consultation notes was submitted and approved by the Department for the June 22, 2021 and October 1, 2020 annual licensing inspections. Including case consultations in the client record was again found to be a deficiency in the June 15, 2022 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.17 (a) (3) - Failure to follow plans of correction
The Division Director will have ultimate responsibility for ensuring that this plan of correction is fully implemented and adhered to on an ongoing basis at the program.
Effective immediately, in addition to the on-site monitoring by the Clinical Supervisor described above, the Division Director and Corporate Outpatient Director will provide ongoing oversight of each plan of correction item and will conduct documented reviews of the plan of correction on a quarterly basis and provide direct feedback to the Clinical Supervisor to be documented in supervision notes.
In addition to the on-site and regional monitoring described above, the Corporate Quality Assurance department will conduct at least quarterly reviews of the program including a physical plant inspection, qualitative and quantitative chart audits, and a specific review of each plan of correction item. Any issues identified during these reviews will be immediately brought to the attention of the Clinical Supervisor to be corrected immediately, as well as being noted on the Quantitative and Qualitative audit tools, and on the summary sheet which includes a Performance Improvement Plan to be developed in conjunction with the Clinical Supervisor and Division Director. Any missing documentation or documentation requiring correction will be completed by the clinician within 48 hours.
Target Date: 7/15/22
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