INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 12, 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 DRC Inc. 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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705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the facility's January 2022 through December 2022 fire drill logs, the facility failed to ensure that a fire alarm or a smoke detector was set off for every drill conducted as neither were set off during the July 2022 drill.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will train the clinical supervisor on fire drills and how to complete the forms by 02/10/23.
The Program Director and/or Clinical Supervisor will ensure that the fire alarm or smoke detector is activated during monthly fire drills.
After each monthly drill, the Program Director will review the fire drill form to ensure that it has been completed appropriately.
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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility failed to follow their written procedures for the management of treatment and rehabilitation services, pertaining to case consultations occurring at day 90 and every 90 days thereafter, for six of six applicable client records reviewed.
Client #1 was admitted on April 12, 2021 and discharged on February 10, 2022. There was no documentation that a case consultation occurred by the time of discharge.
Client #4 was admitted on June 3, 2022 and discharged on November 16, 2022. There was no documentation that a case consultation occurred by the time of discharge.
Client #5 was admitted on February 15, 2022 and was active at the time of the inspection. A case consultation note was entered for August 4, 2022, and the next case consultation was due to be completed by November 4, 2022; however, no additional case consultations occurred prior to the inspection.
Client #6 was admitted on July 25, 2022 and was active at the time of the inspection. The record contained no documentation of case consultation notes.
Client #7 was admitted on August 13, 2021 and was active at the time of the inspection. A case consultation note was entered for March 5, 2022, and the next case consultation was due to be completed by June 5, 2022; however, it was not completed until July 19, 2022.
Client #8 was admitted on June 6, 2022 and was active at the time of the inspection. The record contained no documentation of case consultation notes.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
Program Director will facilitate a training by 02/10/2023 with clinical staff to review the workflow of clinical documentation.
The Clinical Supervisor will be trained in the Clinical Forms Audit Report to aid in monitoring the timeliness of documentation completion.
The Clinical Supervisor will perform a clinical forms audit to ensure that all client files are current for case consultations.
The Program Director/Clinical Supervisor will audit a sample of clinical charts at least monthly, to include a review of case consultation notes. Any deficiencies noted will be addressed with specific clinicians in clinical supervision and corrections made within 3 days.
The Quality Assurance Department will conduct at least quarterly reviews to include audits of clinical records, the findings of which will be discussed with the program, and action steps developed. These reviews include monitoring of all Plans of Correction to ensure full implementation.
Case consultations will be completed by 01/20/23 for clients 5,6 and 8.
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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 four applicable client records, the facility failed to ensure that treatment and rehabilitation plans were reviewed updated at least every 60 days in two records reviewed.
Client #5 was admitted on February 15, 2022 and was active at the time of the inspection. A treatment plan update was completed on August 4, 2022 and a treatment plan update was due to be completed by October 4, 2022; however, the next treatment plan update was not completed until December 2, 2022.
Client #7 was admitted on August 13, 2021 and was active at the time of the inspection. A treatment plan update was completed on December 11, 2021 and a treatment plan update was due to be completed by February 11, 2022; however, the next treatment plan update was not completed until March 18, 2022. The next treatment plan update was due to be completed by May 18, 2022, however, it was not completed until July 19, 2022. The following treatment plan update was due to completed by September 19, 2022; however, not additional treatment plan updates were completed prior to the inspection.
This is a repeat citation from the December 15, 2021 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will facilitate training with all clinicians to review the workflow by 02/10/2023.
The Clinical Supervisor will be trained in the Treatment Plan Analysis Report to aid in monitoring the timeliness of treatment plan completion.
The Clinical Supervisor will perform a clinical forms audit to ensure that all client files are current for treatment plans.
The Corporate OP Director will conduct training for all clinicians to review the proper completion of treatment plans.
The Program Director/Clinical Supervisor will audit a sample of clinical charts at least monthly, to include a review of treatment plan updates. Any deficiencies noted will be addressed with specific clinicians in clinical supervision and corrections made within 3 days.
The Quality Assurance Department will conduct at least quarterly reviews to include audits of clinical records, the findings of which will be discussed with the program, and action steps developed. These reviews include monitoring of all Plans of Correction to ensure full implementation.
Last treatment plan for client 7 was updated on 12/01/22. |
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 ensure that counseling services were provided according to the individual treatment and rehabilitation plans in four of seven applicable records reviewed.
Client #3 was admitted on June 16, 2022 and was discharged on July 26, 2022. The treatment plan completed on June 16, 2022, indicated that the client was to receive one individual session per week; however, the record contained no documentation of individual sessions the weeks of June 20, 2022, July 4, 2022, and July 11, 2022.
Client #4 was admitted on June 3, 2022 and discharged on November 16, 2022. The treatment plan completed on July 1, 2022, indicated that the client was to receive one individual session per week; however, the record contained no documentation of an individual sessions since August 19, 2022.
Client #5 was admitted on February 15, 2022 and was active at the time of the inspection. The treatment plan completed on August 4, 2022, indicated that the client was to receive one individual session per week; however, the record only contained documentation of four individual sessions between September 9, 2022 and December 2, 2022.
Client #8 was admitted on June 6, 2022 and was active at the time of the inspection. The treatment plans completed on August 10, 2022 and October 10, 2022, indicated that the client was to receive one individual session per week; however, the record only contained documentation of three individual sessions between September 1, 2022 and November 17, 2022.
This is a repeat citation from the December 15, 2021 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will conduct an in-service with clinical staff to review service provision according to treatment plan by 02/10/2023.
The Corporate OP Director will conduct training for all clinicians to review the proper components of treatment plans.
The Clinical Supervisor will be trained in the Treatment Plan Analysis Report to aid in monitoring the timeliness of treatment plan completion.
Counselors will document instances of missed appointments to include a reason for the absence and any follow up efforts made by the Counselor.
The Counselor will route completed treatment plans to the Clinical Supervisor for final approval.
The Clinical Supervisor will run the Notes Audit Report weekly to monitor the timeliness of session note entry.
The Program Director/Clinical Supervisor will audit a sample of clinical charts at least monthly, to include a review of treatment plan updates. Any deficiencies noted will be addressed with specific clinicians in clinical supervision and corrections made within 3 days.
The Quality Assurance Department will conduct at least quarterly reviews to include audits of clinical records, the findings of which will be discussed with the program, and action steps developed.
These reviews include monitoring of all Plans of Correction to ensure full implementation.
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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 a complete client record included information relative to the client's involvement with the project to include follow-up information in one of two applicable records reviewed.
Client #2 was admitted on March 2, 2022 and was discharged on April 26, 2022. The client record did not contain documentation of follow-up information.
This is a repeat citation from December 14, 2021 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will facilitate in-service staff training to include discussion of follow-up requirements and the use of the available Follow Up Contact Widget in the electronic health record by 02/10/2023.
Counselors will use the Follow Up Contact Widget to track clients post-discharge for follow up according to established timelines.
Counselors will document each follow up attempt on the Follow-Up Contact Note in the electronic health record.
Primary Counselors and/or designee of the Clinical Supervisor or Program Director shall assume responsibility for client follow-up.
The Program Director/Clinical Supervisor will audit a sample of clinical charts at least monthly, to include a review of follow-up documentation.
The Quality Assurance Department will conduct at least quarterly reviews to include audits of clinical records, the findings of which will be discussed with the program, and action steps developed.
These reviews include monitoring of all Plans of Correction to ensure full implementation.
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