INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 8, 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, 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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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of six personnel records, the facility failed to document that the clinical supervisor participated in documented monthly meetings with their supervisor to discuss their duties and performances for the first six months of employment in that position. Employee #3, who was hired as a clinical supervisor on August 1, 2023 and was still employed in that position at the time of the inspection did not have documented monthly supervision from August 2023 through January 2024. This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The new division director started on 4/8/24. Supervision began on 4/17/24 and will continue on a monthly basis. Outpatient Director reviewed with Division Director the expectations for supervision of newly hired supervisors. Outpatient Director will review that supervision is occurring during monthly supervision with the Division Director. |
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/rehabilitation services for clients in three of six applicable client records reviewed. The policy states that treatment plan updates would be completed every thirty days for the intensive outpatient program and every sixty days for the outpatient program.Client #2 was admitted to the outpatient program on December 11, 2023 and was still active at the time of the inspection. A treatment plan was completed on January 9, 2024, and the next update was due no later than March 9, 2024; however, there was no documentation that one was completed. Client #3 was admitted to the intensive outpatient program on November 10, 2023 and was still active at the time of the inspection. A treatment plan was completed on December 7, 2023, and the next update was due no later than January 7, 2024; however, it was not completed until January 25, 2024. The next treatment plan update was due no later than February 25, 2024; however, it was not completed until February 29, 2024. Client #5 was admitted to the outpatient program on September 6, 2023 and discharged on December 8, 2023. A treatment plan update was completed on October 6, 2023, and the next update was due no later than December 6, 2023; however, there is no documentation that one was completed.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Starting May 10, 2024, Clinical Supervisor will run the Treatment Plan Analysis report on a monthly basis and send out emails to staff about tx plan coming due or past due. CS will follow up to ensure they are completed. By May 10th the clinical supervisor will review with all staff the treatment plan widget on their My Day Page as a way to track treatment plan due dates as well with the expectation they will begin to use it |
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 records, 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 seven records reviewed.Client #4 was admitted on July 19, 2023 and discharged on October 24, 2023. There was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the insurance was billed for the services. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 4/24/24 a meeting was held about releases of information, consents with all staff. On May 7, 2024 we will begin Open Access and staff will be reviewing the workflow related to OA. The CS will review weekly the assessments completed to ensure the workflow is being followed by all counselors. Any noted outstanding paperwork will addressed at that time with counselor to fix. |
709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Based on a review of facility records, the facility failed to file a written unusual incident report with the Department within 3 business days following an unusual incident involving the death or serious injury due to trauma, suicide, medication error or unusual circumstances.The facility was notified on November 28, 2023 that an active client was deceased. Upon review of unusual incidents submitted to the Department, it was found that this incident had not been reported at the time of the inspection. This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Division Director will review with the Clinical Supervisor that anytime an incident requires an DDAP Unusual Incident report we will print them and attach them to our internal incident report management system. For the two outstanding reports we will have the new Facility Director complete them and enter them into the DDAP system by 5/31/24. The Division Director will follow up with Clinical Supervisor during monthly supervision to ensure that any incident reports requiring a DDAP Unusual Incident report are completed and uploaded in our Incident Managment System. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of facility records, the facility failed to file a written unusual incident report with the Department within 3 business days following an unusual incident involving an event at the facility requiring the presence of police, fire or ambulance personnel.An ambulance was at the facility on January 29, 2024. Upon review of unusual incidents submitted to the Department, it was found that this incident had not been reported at the time of the inspection. This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Division Director will review with the Clinical Supervisor that anytime an incident requires an DDAP Unusual Incident report we will print them and attach them to our internal incident report management system. For the two outstanding reports we will have the new Facility Director complete them and enter them into the DDAP system by 5/31/24. During monthly supervisions with the Clinical Supervisor, Division Director will ensure any incident report requiring a DDAP Unusual Incident report will be completed and uploaded into our Incident Management System. |