INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 7, 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 at Sunbury 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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709.25 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.
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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 seven client records, the facility failed to document treatment plan updates within the regulatory timeframe in five of the seven client records reviewed.
Client #1 was admitted on February 23, 2022 and was still active at the time of the inspection. A treatment plan update was completed on February 23, 2022, and the next update was due no later than April 23, 2022; however, there was no update documented in the record at the time of the inspection.
Client #2 was admitted on December 29, 2021 and was still active at the time of the inspection. A treatment plan update was completed on December 29, 2021, and the next update was due no later than March 1, 2022; however, there was no update documented in the record at the time of the inspection
Client #5 was admitted on August 4, 2021 and discharged on April 1, 2022. A treatment plan update was completed on September 24, 2021, and the next update was due no later than November 24, 2021; however, there was no update documented in the record at the time of the inspection.
Client #6 was admitted on September 20, 2021 and discharged on February 8, 2022. A treatment plan update was completed on November 30, 2021, and the next update was due no later than January 24, 2022; however, there was no update documented in the record at the time of the inspection.
Client #7 was admitted on February 3, 2022 and discharged on May 31, 2022. A treatment plan update was completed on March 3, 2022, and the next update was due no later than May 3, 2022; however, there was no update documented in the record at the time of the inspection.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
An all-staff in-service meeting was held on June 16, 2022 to address clinical staff on treatment management procedures specific to the treatment plan update process.
All staff were directed to update treatment plans at least every 30 days for IOP and 60 days for OP. Should the client not attend the scheduled session to develop treatment plans as scheduled, clinical staff will proceed to update the plan as appropriate and document that the plan will be reviewed with the client during the next attended session and updated as needed at that time.
The Clinical Supervisor will review treatment plans for compliance during monthly audits. This will be reviewed with Clinical staff in documented regular supervisory sessions.
The Quality Assurance department will complete at least quarterly reviews, to include audits of treatment plan updates for completion. Any issues noted in this area will result in the development of a performance improvement plan.
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709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of the facility ' s policy and procedure manual and seven client records, the facility failed to complete and document at least one case consultation every 90 days in seven of the seven client records reviewed.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All active clients will have case consultations completed within 90 days, or at least once during treatment if the course of treatment is expected to be less than 90 days.
Counselors and Clinical Supervisor will meet on a weekly basis to complete case consultations regarding the individuals for whom one is due that week. During these meetings, clinicians discuss the overall progress or concerns regarding each client. The primary counselor is responsible for completing the case consultation documentation. This documentation is to include the date of consult, names of attending staff and titles, client name, summary of discussion and disposition of case reviewed. The case consult will be signed by the primary counselor and reviewed for thoroughness and completeness and routed to the Clinical Supervisor and any other clinician involved in the discussion for signatures.
The Clinical Supervisor and Division Director met with clinical staff for an in-service training to review completing a case consult form on June 16, 2022 during all staff meeting.
Division Director and Clinical Supervisor will also review client files monthly for Quality Assurance and report results to staff and senior management.
The Quality Assurance department will complete at least quarterly reviews, to include audits of case consultation documentation for completion. Any issues noted in this area will result in the development of a performance improvement plan.
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709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of seven inpatient client records, the facility failed to provide a complete client record, which is to include an aftercare plan in one of the three applicable client records.
Client #5 was admitted on August 4, 2021 and was discharged on April 1, 2022 The client record did not contain documentation that an aftercare plan was completed.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
An all-staff meeting was held on 6/16/2022 to address clinical staff on treatment management procedures specific to continuing care/transition/discharge plan summaries. Clinical staff were reminded that discharge documentation is due in the client chart within 7 days of discharge. The continuing care/transition/discharge plan summary needs to be completed in its entirety at the time of discharge. Gaudenzia's comprehensive workflow documentation for discharge will be followed. The Division Director will review for compliance during the monthly internal CQI process. Clinical staff will be monitored monthly in regular supervisory sessions. Additionally, audits that are documented on the quantitative audit tool are conducted monthly by either the Corporate Outpatient Director, Division Director, or Regional Quality Assurance department to ensure compliance. All audits are documented monthly, and the Regional Quality Assurance department completes a quarterly CQI report. |
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 a review of seven inpatient client records, the facility failed to provide a complete client record, which is to include discharge summaries in one of the three applicable client records reviewed.
Client #5 was admitted on August 4, 2021 and was discharged on April 1, 2022. The client record did not contain documentation that a discharge summary was completed.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
An all-staff meeting was held on 6/16/2022 to address clinical staff on treatment management procedures specific to continuing care/transition/discharge plan summaries. Clinical staff were reminded that discharge documentation is due in the client chart within 7 days of discharge. The continuing care/transition/discharge plan summary needs to be completed in its entirety at the time of discharge. Gaudenzia's comprehensive workflow documentation for discharge will be followed. The Division Director will review for compliance during the monthly internal CQI process. Clinical staff will be monitored monthly in regular supervisory sessions. Additionally, audits that are documented on the quantitative audit tool are conducted monthly by either the Corporate Outpatient Director, Division Director, or Regional Quality Assurance department to ensure compliance. All audits are documented monthly, and the Regional Quality Assurance department completes a quarterly CQI report. |