INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 10, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Common Ground 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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709.28 (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 client records and discussion with facility staff, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one out of ten records reviewed.
Client #8 was admitted on April 18, 2023 and still active at the time of the inspection. There was not an informed and voluntary consent to disclose information form for the funding source in the client record. The facility staff confirmed billing had occurred.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
709.28 - Confidentiality
Consents will be completed for all funding sources, including when a client changes funder during treatment.
The consent for this individual was completed immediately, on 5/10/23.
All clinical and medical staff were reminded of this requirement on 5/10/23.
This will be monitored via regular audits of a sample of clinical charts to be completed on an at least monthly basis by the Clinical Supervisor and/or Program Director, and on an at least quarterly basis by the QA manager. Any issues noted will be addressed with the staff member in a documented supervision session, and corrected within 48 hours.
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709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to document a complete psychosocial evaluation in three out of seven records within 72 hours of admission, per the facility ' s policy and procedures manual.
Client #8 was admitted on April 18, 2023 and was still active at the time of the inspection. A psychosocial evaluation was due no later than April 21, 2022; however, there is no documentation one was completed.
Client # 9 was admitted on April 6, 2023 and was still active at the time of the inspection. A psychosocial evaluation was due no later than April 9, 2023: however, there is no documentation one was completed.
Client # 10 was admitted on April 17, 2023 and was still active at the time of the inspection. A psychosocial evaluation was due no later than April 20, 2023; however, there was no documentation that one was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.51 b 6 - Psychosocial Evaluation
This was precipitated by a change in our electronic document. Though the Biopsychosocial History is now a separate document from the Interpretive Summary (Psychosocial Evaluation), they are now bundled together to avoid this oversight in the future.
All clinical staff were educated regarding this requirement and how to complete all required documentation in the area on 5/11/2023.
The Interpretive Summary was completed for all active clients for whom it was missing as of DATE 5/15/2023
This will be monitored via regular audits of a sample of clinical charts to be completed on an at least monthly basis by the Clinical Supervisor and/or Program Director, and on an at least quarterly basis by the QA manager. Any issues noted will be addressed with the staff member in a documented supervision session, and corrected within 48 hours.
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