INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 22, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gaudenzia West Shore 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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709.26 (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 one of three applicable employee personal records reviewed, the facility failed to ensure that annual written individual staff performance evaluations, were reviewed and signed by the employee per the facility's policy and procedure manual in one out of three personnel records reviewed. The facility's policy and procedure manual states that the annual job performance evaluations are due at the beginning of each calendar year. Project staff indicated evaluations specifically are to be completed and signed by February 1 each year.
Employee # 1 was hired as the Project Director on September 9, 2019, and is current in that position. The annual written staff performance evaluation was due to be reviewed and signed by the employee by February 1, 2024, however, it was not signed by the employee until February 28, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By June 30, 2024, Division Director will speak to the Clinical Supervisors at all programs to let them know the expectation is to review the annual reviews with all staff one week prior to due rate for reviews. Upon completion of annual performance evaluation and review with the staff member, supervisor will immediately release it to the staff member for signature. Clinical Supervisor will monitor for completed signature following each review. Division Director will pull completion report each day up until the final day of when annual performances reviews are due and follow up as needed. |
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 one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
Client # 2 was admitted on March 6, 2024, and was still active at the time of the inspection. There was not an informed and voluntary consent from the client for the disclosure of information in the client record to a funding source. Facility staff confirmed billing was occurring.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By June 30, 2024, Clinical Supervisor will conduct an in-service training with members of clinical team to address the procedure and workflow of obtaining the required release form for client funding source. This process will be monitored through monthly chart audit reviews by the Clinical Supervisor to ensure compliance of obtaining the required release for funding source.
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709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on four of eight applicable client records reviewed, the facility failed to provide a preliminary treatment plan in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicated a preliminary treatment plan be on the first session with the client.
Client # 1 was admitted on February 23, 2024, and was still active at the time of the inspection. There was no preliminary treatment plan documented in the client record.
Client # 3 was admitted on March 21, 2024, and was still active at the time of the inspection. A preliminary treatment plan was due March 21, 2024; however, did not occur until March 28, 2024.
Client # 4 was admitted on February 15, 2024, and was still active at the time of the inspection. A preliminary treatment plan was due February 15, 2024; however, did not occur until February 19, 2024.
Client # 7 was admitted on October 24, 2023, and was discharged on March 12, 2024.
A preliminary treatment plan was due October 26, 2023; however, did not occur until December 1, 2023.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the May 12, 2023, annual licensing inspection.
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Plan of Correction
By June 30, 2024, Clinical Supervisor will review the Workflow with all members of the clinical team to ensure that the Preliminary Tx Plan is being completed at time of intake/admission to the program. Overview of the required Preliminary Tx Plan will then be a part of the routine monthly chart audit review process conducted by Clinical Supervisor. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on three of seven applicable client records reviewed, the facility failed to provide an individual treatment and rehabilitation plan developed with the client to include the frequency of treatment and rehabilitation services.
Client # 1 was admitted on February 23, 2024, and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on April 8, 2024, however, there was no documentation of frequency for groups.
Client # 3 was admitted on March 21, 2024, and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on March 29, 2024, however, there was no documentation of frequency for groups.
Client # 4 was admitted on February 15, 2024, and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on March 6, 2024, however, there was no documentation of for frequency groups.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By June 30th, 2024, Clinical Supervisor will conduct on in-service training with members of the treatment team on the process of including programming service frequency on client treatment plans. Overview of this requirement will be conducted through routine monthly chart audit reviews by the Clinical Supervisor. |
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 four of seven applicable client records reviewed, the facility failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan.
Client # 1 was admitted on February 23, 2024, and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan developed on April 8, 2024, indicated an individual session weekly. An individual session was only documented for April 8 and 22, May 6 and 21, 2024.
Client # 2 was admitted on March 6, 2024, and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan developed on March 14, 2024, indicated an individual session occur bi- weekly and groups weekly. Individual sessions were only documented for March 14 and 19. Group sessions were only documented for March 28, April 2, 11, 24, 2024.
Client # 4 was admitted on February 15, 2024, and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan developed on March 6, 2024, indicated an individual session bi-weekly and the treatment and rehabilitation plan update on April 3, 2024, indicated an individual session occur one time weekly and a group session occur one time weekly. Individual sessions were only documented for March 6, 20, April 3, 17, 30, 2024. Group sessions were only documented for March 4. 7, 11, 14, 18, 21, 25, 29, April 1, 4, 8, 11, 19, 23, and May 1, 6, 13, 2024.
Client # 5 was admitted on July 10, 2023, and was discharged on September 20, 2023. A comprehensive treatment and rehabilitation plan developed on July 21, 2023, indicating individual sessions bi-weekly and groups one to two times a week. Individual sessions were only documented for July 21, August 18, and September 20, 2023. Group sessions were only documented for July 23, 24, 30, 31, August 3, 7, 10, 14, 21, 24, 28, and September 7, 11, 14, 2023.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the May 12, 2023, annual licensing inspection.
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Plan of Correction
By June 30, 2024, the Clinical Supervisor will conduct an in-service training during clinical team meeting regarding the frequency of individual sessions and how this should be reflected accurately on the treatment plan. Documentation of missed sessions will also be reviewed during this in-service training. Overview of the frequency of sessions as identified on comprehensive treatment plan and documentation of missed sessions will be a part of the routine monthly chart audit review process conducted by Clinical Supervisor. |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on four of eight applicable client records reviewed, the facility failed to provide a complete client record to include progress notes that included an individual assessment of the client ' s participation in the session.
Client # 1 was admitted on February 23, 2024, and was still active at the time of the inspection. There was not an individual assessment of the client ' s participation documented, the assessment was the same for multiple group members.
Client # 2 was admitted on March 6, 2024, and was still active at the time of the inspection. There was not an individual assessment of the client ' s participation documented, the assessment was the same for multiple group members.
Client # 3 was admitted on March 21, 2024, and was still active at the time of the inspection. There was not an individual assessment of the client ' s participation documented, the assessment was the same for multiple group members.
Client # 4 was admitted on February 15, 2024, and was still active at the time of the inspection. There was not an individual assessment of the client ' s participation documented, the assessment was the same for multiple group members.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By June 30, 2024, Clinical Supervisor will conduct an in-service training on the process for individualizing group process notes to include a more specific and individualized assessment section in group notes for each individual client. Overview of this assessment adherence will be a part of the routine monthly chart audit review process conducted by the Clinical Supervisor. |
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
Based on two of four applicable client records reviewed, the facility failed to provide a discharge summary in accordance with the facility policy and procedure manual. The policy and procedure manual indicates a discharge summary be completed within 7 days of discharge.
Client # 6 was admitted on September 11, 2023, and was discharged on October 17, 2023. The discharge summary was due to be completed no later than October 24, 2023, however, the discharge summary was not documented.
Client # 7 was admitted on October 24, 2023, and was discharged on March 12, 2024. The discharge summary was due to be completed no later than March 19, 2024, however, the discharge summary was not documented.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the May 12, 2023, March 31, 2022, and August 24, 2021, annual licensing inspection.
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Plan of Correction
Starting June 30, 2024, the Clinical Supervisor will run the discharge analysis report weekly and send emails to counselors of outstanding and upcoming discharge paperwork. Clinical team members are to address any discharge paperwork during their 2 hours of allotted admin/paperwork time per week. Overview of this discharge summary adherence will be a part of the routine monthly chart audit review process by the Clinical Supervisor. |
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 four of eight applicable client records reviewed, the facility failed to provide follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a follow-up to occur within 7 days of referral or 30 days after discharge.
Client # 5 was admitted on July 10, 2023, and was discharged on September 20, 2023. There was no follow-up information available in the client record.
Client # 6 was admitted on September 11, 2023, and was discharged on October 17, 2023. There was no follow-up information available in the client record.
Client # 7 was admitted on October 24, 2023, and was discharged on March 12, 2024. There was no follow-up information available in the client record.
Client # 8 was admitted on September 28, 2023, and was discharged on March 13, 2024. There was no follow-up information available in the client record.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the May 12, 2023, and March 31, 2022, annual licensing inspection.
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Plan of Correction
By June 30, 2024 Clinical Supervisor will review the follow up policy and expectations with the clinical team in clinical team meeting. Documentation of the follow up process will also be reviewed in this meeting. Overview of the follow up process will be part of the routine monthly chart audit review process for discharged client charts by the Clinical Supervisor. |
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.
Plans of correction for follow up information were submitted and approved by the Department for the May 12, 2023, and March 31, 2022, licensing inspections. Follow up information was again found to be a deficiency in the May 22, 2024, licensing inspection.
Plans of correction for completing discharge summaries were submitted and approved by the Department for the May 12, 2023, March 31, 2022, and August 24, 2021 licensing inspections. Discharge summary information was again found to be a deficiency in the May 22, 2024, licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning June 17th, 2024 and occurring on a monthly basis, the Division Director will attend a CQI meeting. On the agenda of the CQI meeting is to review and present that POCs are being followed at the program level. The Division Director will report updates after completing monthly charts prior to the call, for the program as a way to monitor implementation and adherence of the POC. Any deficiencies will be reviewed with Program Director the same day of the meeting and follow through with documentation will be requested. This will continue throughout the year. |