INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 17, 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. Vantage House 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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705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
During a physical plant inspection on May 17, 2022, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times.
The toilet in the daycare area had a cracked tank lid with a sharp edge.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
A replacement was ordered immediately and delivered, but it did not fit the toilet tank. A properly-fitting replacement has been ordered and will be installed no later than 6/30/22. Daily safety rounds will include inspection of all bathrooms and to ensure that all fixtures are in good working order. Any concerns in this area will be immediately brought to the attention of the Program Director and immediate action take to address the situation. Bathroom maintenance is a specific item on the run sheet that is completed for each run. These run sheets are maintained in a log and will be reviewed at least monthly by the Program Director to ensure that they are being completed. The Quality Assurance Department will conduct at least quarterly reviews of all programs, to include a review of all plans of correction to ensure full implementation. |
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
The Annual Financial Audit for the most recent fiscal year (FY 2020 ? 2021) was not completed in a timely manner due to the 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. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in four out of seven client records reviewed.
Client #1 was admitted on November 2, 2021 and was still current at the time of the inspection. A treatment plan update was completed on February 25, 2022, and the next update was due by March 25, 2022, however one was not documented until April 1, 2022. The next was due by May 1, 2022, however one was not documented until May 5, 2022.
Client #2 was admitted on November 30, 2021 and was current at the time of the inspection. A treatment plan update was completed on January 31, 2022, with the next update due no later than March 3, 2022, however, one was not documented until March 4 ,2022.
Client #3 was admitted on December 6, 2021 and was current at the time of the inspection. A treatment plan update was completed on December 7 ,2021 with the next update due no later than January 7, 2022, however, one was not documented until January 28, 2022. The next update was due no later than February 28, 2022, however, was not documented until March 13, 2022. The next treatment plan was completed on April 13, 2022, however there were no more documented at the time of the inspection.
Client #5 was admitted on June 16, 2021 and was discharged on December 9, 2021. A treatment plan update was completed on June 21, 2021, with the next update due no later than July 21, 2021, however, one was not documented until July 23, 2021. The next update was due no later than August 23, 2021, however, was not documented until August 25,2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will be re-trained in an in-service no later than 6/17/22 conducted by the Clinical Supervisor regarding treatment plan updates, and how to properly document this in the record. An internal tracking tool for each chart has been developed to help remind staff of upcoming documentation requirements. This includes treatment plan updates. The Clinical Supervisor will send a reminder to clinicians at the beginning of each month noting which clients are due for Treatment Plan updates. Clinical staff will send all treatment plans to Clinical Supervisor for approval. Upcoming updated treatment plans will be reviewed in weekly Clinical Staff meeting. The Clinical Supervisor will conduct weekly audits of a sample of charts in order to ensure that timely treatment plan updates are completed for all charts. Any missing documentation will be brought to the attention of the clinician and completed within 48 hours. The Program Director will conduct monthly audits of a sample of charts in order to ensure that timely treatment plan updates are completed for all charts. Any missing documentation will be brought to the attention of the Clinical Supervisor in order to follow
up with the clinician in supervision and completed within 48 hours. The Quality Assurance Department will conduct at least quarterly audits to include all Plans of Correction to ensure full implementation. conducted by the Clinical Supervisor regarding this regulation, and how to properly document this in the record. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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 seven client records, the project failed to have a complete client record on one of three applicable clients that included information relative to the client's involvement with the project, including follow-up information.
Client #5 was admitted on June 16, 2021 and was discharged on December 9, 2021. Client #5 did not have documentation of follow-up information in the client record.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
All clients will be contacted post-discharge and this contact (or attempt) will be documented in our electronic health record on the Follow Up Contact Note created for this purpose. This will occur within 7 days of the date of the referral appointment for completions, and within 30 days for all other discharges. Staff will be re-trained in an in-service no later than 6/17/22 conducted by the Clinical Supervisor regarding this regulation, and how to properly document follow-up in the record using our Follow-Up Contact form. An internal tracking tool for each chart has been developed to help remind staff of upcoming documentation requirements. This includes follow-up post-discharge. The Clinical Supervisor will send a reminder to clinicians at the beginning of each month noting which clients are due for follow-up. Clinical staff will send all treatment plans to Clinical Supervisor for approval. Upcoming follow-ups will be reviewed in weekly Clinical Staff meeting. The Clinical Supervisor will conduct weekly audits of a sample of charts in order to ensure that follow-ups are completed for all discharged charts. Any missing documentation will be brought to the attention of the clinician and completed within 48 hours. The Program Director will conduct monthly audits of a sample of discharged charts. Any missing documentation will be brought to the attention of the Clinical Supervisor in order to follow up with the clinician in supervision and completed within 48 hours. The Quality Assurance Department will conduct at least quarterly audits to include all Plans of Correction to ensure full implementation. |
709.53(a)(12) LICENSURE Work as treatment
709.53. 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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of seven client records, the facility failed to ensure that all work done by the clients at the project is an integral part of their treatment and rehabilitation plan in all seven client records reviewed.
These findings were discussed with facility staff during the inspection process.
This is a repeat citation from an inspection conducted May 27, 2021.
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Plan of Correction
Staff will be re-trained in an in-service no later than 6/17/22 conducted by the Clinical Supervisor regarding this regulation. The Clinical Supervisor will review the treatment plan form, and the specific areas designed to be used to indicate work as treatment as an integral part of the treatment plan. The Clinical Supervisor will conduct weekly audits of a sample of charts in order to ensure that treatment plans properly document work as treatment. Any missing documentation will be brought to the attention of the clinician and completed within 48 hours. The Program Director will conduct monthly audits of a sample of charts. Any missing documentation will be brought to the attention of the Clinical Supervisor in order to follow up with the clinician in supervision and completed within 48 hours. The Quality Assurance Department will conduct at least quarterly audits to include all Plans of Correction to ensure full implementation. |