INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 16, 2024 - May 17, 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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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to provide a written individual training plan for each employee, that documented it was developed annually with input from both the employee and the supervisor in two of five personnel records reviewed.
Employee # 4 has been in the position of counselor since October 1, 2023. The individual training plan had no documentation that the plan was developed with input from both the employee and supervisor and the date completed.
Employee # 5 was hired as a counselor on July 3, 2023. The individual training plan had no documentation that the plan was developed with input from both the employee and supervisor and the date completed.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Program Director will ensure all Staff training plans are developed annually. All training plans will be developed with the staff member; reviewed and signed by staff member and supervisor to document input by both parties.
Program Director/Division Director will develop tracking system to ensure all training plans are completed by designated due date.
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705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of fire drill logs from May 2023 through April 2024, the facility failed to ensure that fire drill logs included the exit route used for each fire drill conducted, except for those conducted in July 2023.
This is a repeat citation from the May 12, 2022 and April 21, 2023 annual licensing renewal inspections.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will educate all staff regarding monthly fire drill procedures, recordings, and documentation requirements, including utilizing alternate exit routes by 7/1/24.
Program Director will provide oversight monthly to ensure fire drills are documented and recorded correctly according to fire safety code
705.10 (D) (4)
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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 fourteen client records, the facility failed to follow their written procedures for the notification of emergency contacts within 12 hours when a client leaves against staff advice in two of two applicable records.
Client # 6 was admitted to the Short-Term Detoxification level of care on April 16, 2024 and was discharged Against Staff Advice (ASA) on April 23, 2024. The facility failed to follow their policy related to ASA discharges of calling the Emergency Contact within twelve hours.
Client # 8 was admitted to the Residential Treatment and Rehabilitation level of care on August 5, 2023 and was discharged ASA on September 2, 2023. The facility failed to follow their policy related to ASA discharges of calling the Emergency Contact within twelve hours.
This is a repeat citation from the May 12, 2022 and April 21, 2023 annual licensing renewal inspections.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
Program Director will review the policy with staff by 7/1/24.
A system was developed to monitor adherence to policy as well as addressing procedures for handling ASAs outside of clinical staff presence.
The Clinical Supervisor will conduct a daily audit with the clinical team. The Program Director will conduct a monthly audit to ensure compliance. |
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 a review of personnel records, 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 two of two applicable 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.
Employee # 2 was hired as the Facility Director on January 27, 2020 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 22, 2024.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All Gaudenzia Managers will ensure that Annual Performance Evaluations are completed, reviewed with the employee during a documented supervision session, and acknowledged via signature by both parties no later than February 1st of each year.
The Chief Executive Officer will ensure that this process is completed for the Project Director.
The Deputy Directors will ensure that this process is completed for all Division Directors.
The Division Directors will complete Annual Performance Evaluations for each of the Program Directors that they oversee and will also ensure that these Program Directors complete Annual Performance Evaluations for the staff that they oversee.
The Quality Assurance department will review staff files during semi-annual program reviews to ensure compliance.
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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 twenty-one client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in one record reviewed.
Client # 14 was admitted to the Residential Treatment and Rehabilitation level of care on April 23, 2024 and was active at the time of the inspection. The record contained documentation of a disclosure of information to a government agency on May 13, 2024, however, the record did not contain a client signed consent to release information form to the agency. Additionally, the record contained documentation of disclosures of information to another treatment provider on May 14, 2024, and May 15, 2024; however, the record did not contain a client signed consent to release information form to the provider.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will review consents as part of the audit process.
Clinical supervisor will identify deficiencies and address with appropriate staff members to ensure compliance.
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709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records and the facility's policies and procedure manual, the facility failed to document a psychosocial evaluation, within 72 hours of admission as per policy, in five of six applicable records reviewed.
Client # 1 was admitted on November 8, 2023 and was transferred to a lower level of care on November 14, 2023. The record did not contain a psychosocial evaluation.
Client # 3 was admitted on January 10, 2024 and was transferred to a lower level of care on January 16, 2024. The record did not contain a psychosocial evaluation.
Client # 4 was admitted on July 15, 2023 and was transferred to a lower level of care on July 23, 2023. The psychosocial evaluation was not completed until August 22, 2023.
Client # 5 was admitted on July 1, 2023 and was discharged on July 7, 2023. The record did not contain a psychosocial evaluation.
Client # 7 was admitted on May 11, 2024 and was active at the time of the inspection. The record did not contain a psychosocial evaluation.
This is a repeat citation from the April 21, 2023 annual licensing renewal inspection.
These finding were discussed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will review biopsychosocial as part of their weekly audit to ensure the required documentation is being completed according to required time frames and workflow.
Clinical supervisor will conduct weekly checks to ensure the evaluations are completed as required.
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709.63(a)(2) LICENSURE D & A support plan
709.63. 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:
(2) Drug and alcohol support plan.
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Observations
Based on a review of seven client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include a drug and alcohol support plan completed within 24 hours, which is the policy of the project, in three of six applicable records reviewed.
Client # 3 was admitted on January 10, 2024 and was transferred to a lower level of care on January 16, 2024. The drug and alcohol support plan was due to be completed by January 11, 2024; however, it was not completed prior to the client ' s transfer.
Client # 4 was admitted on July 15, 2023 and was transferred to a lower level of care on July 23, 2023. The drug and alcohol support plan was due to be completed by July 16, 2023; however, it was not completed until July 23, 2023.
Client # 6 was admitted on April 16, 2024 and was transferred to a lower level of care on April 23, 2024. The drug and alcohol support plan was due to be completed by April 17, 2024; however, it was not completed until April 22, 2024.
This is a repeat citation from the May 12, 2022 and April 21, 2023 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will review policy with all clinical staff by July 1, 2024.
The Clinical Supervisor will run Clinical Scorecard Report daily and will review with clinical team during daily morning meeting.
Program Director will conduct monthly chart audits to ensure compliance.
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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 a review of seven client records and the facility's policies and procedures, the facility failed to document a psychosocial evaluation within five days of admission, per facility policy, in two of five applicable records reviewed.
Client # 8 was admitted on August 5, 2023 and was discharged on September 2, 2023. The record did not contain a psychosocial evaluation.
Client # 13 was admitted on March 29, 2024 and was active at the time of the inspection. The record did not contain a psychosocial evaluation.
These finding were discussed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will review policy with all clinical staff by July 1, 2024.
The Clinical Supervisor will run Clinical Scorecard Report daily and will review with clinical team during daily morning meeting. Any missing documentation will be addressed with clinician.
Program Director will conduct monthly chart audits to ensure compliance.
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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 seven client records, the facility failed to document treatment plan updates within the regulatory timeframe in two of two applicable records reviewed.
Client # 9 was admitted on February 16, 2024 and was discharged on April 15, 2024. The individual treatment and rehabilitation plan was completed on March 2, 2024, and the treatment plan update was due no later than March 17, 2024; however, the update was not completed until March 22, 2024.
Client # 13 was admitted on March 29, 2024 and was active at the time of the inspection. A treatment plan update was completed on April 25, 2024, and the next treatment plan update was due no later than May 10, 2024; however, the update was not completed until May 16, 2024.
This is a repeat citation from the April 21, 2023 annual licensing renewal inspection.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Clinical Supervisor will review policy with all clinical staff by July 1, 2024.
The Clinical Supervisor will run Clinical Scorecard Report daily and will review with clinical team during daily morning meeting. Any missing documentation will be addressed with clinician.
The Program Director will conduct monthly chart audits to ensure compliance.
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709.52(c) LICENSURE Provision of Counseling Services
709.52. 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 a review of client records, the facility failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plans in four of six applicable records reviewed.
Client # 9 was admitted on February 16, 2024 and was discharged on April 15, 2024. The treatment plans completed on February 18, 2024, March 2, 2024, March 22, 2024, and March 29, 2024, indicated that the client was to receive one individual session per week; however, the record did not document individual sessions offered the weeks of February 26, 2024, March 25, 2024, and April 8, 2024.
Client # 10 was admitted on January 16, 2024 and was discharged on February 13, 2024. The individual treatment and rehabilitation plan completed on January 24, 2024, indicated that the client was to receive one individual session per week; however, the record contained no documentation of an individual session between January 22, 2024 and February 13, 2024.
Client # 12 was admitted on July 23, 2023 and was discharged on August 21, 2023. The treatment plans completed on August 1, 2023 and August 17, 2023, indicated that the client was to receive one individual session per week; however, the record contained no documentation of individual sessions offered the weeks of July 31, 2023 and August 14, 2023.
Client # 13 was admitted on March 29, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan completed on July 28, 2023, indicated that the client was to receive one individual session per week; however, the record contained no documentation of an individual session the weeks of July 31, 2023 and August 7, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinicians will post schedule of weekly meeting times with clients outside their door.
The Clinical Supervisor will utilize notes audit to track that individual sessions are occurring within 7 days. Any issues noted, will be brought to the clinician's attention immediately.
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709.53(a)(5) LICENSURE Progress Notes
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:
(5) Progress notes.
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Observations
Based on a review of client records and the facility policies and procedures, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include progress notes completed immediately after therapy sessions, per facility policy, in three of seven records reviewed.
Client # 10 was admitted on January 16, 2024 and was discharged on February 13, 2024. The record contained a progress note for an individual session occurring on January 22, 2024, that was not completed until January 31, 2024.
Client # 11 was admitted on February 7, 2024 and was discharged on March 5, 2024. The record contained a progress note for an individual session occurring on February 16, 2024, that was not completed until March 11, 2024.
Client # 12 was admitted on July 23, 2023 and was discharged on August 21, 2023. The record contained a progress note for an individual session occurring on July 27, 2023, that was not completed until August 8, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will meet with clinicians to review policy for completion and time management techniques to maintain compliance by July 1, 2024.
The Clinical notes audit will be reviewed by the clinical supervisor on a weekly basis to ensure all progress notes are entered.
The Program Director will conduct audits monthly to ensure compliance.
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709.53(a)(8) LICENSURE Case Consultation Notes
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:
(8) Case consultation notes.
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Observations
Based on a review of client records and the facility ' s policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include case consultation notes prior to the end of the treatment episode, in four of six applicable records reviewed.
Client # 8 was admitted on August 5, 2023 and was discharged on September 2, 2023. There was no documentation of case consultation notes in the record.
Client # 10 was admitted on January 16, 2024 and was discharged on February 13, 2024. The case consultation note was not documented until March 13, 2024, which was after the episode.
Client # 11 was admitted on February 7, 2024 and was discharged on March 5, 2024. There was no documentation of case consultation notes in the record.
Client # 12 was admitted on July 23, 2023 and was discharged on August 21, 2023. There was no documentation of case consultation notes in the record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will conduct weekly chart audits and the Quality Assurance Department will conduct semi annual clinical chart audits focusing on the case consultation process. Chart audits will focus on ensuring case consults are completed within 15 days of admission and every 90 days thereafter.
The Program Director will ensure that all staff is trained on how to complete case consults in accordance with DDAP requirements and agency protocol by 7/1/24.
All active clients who have not engaged in the case consult process will be provided with case consults by 7/10/24.
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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 client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include follow-up information, in three of four applicable records reviewed.
Client # 9 was admitted on February 16, 2024 and was discharged on April 15, 2024. There was no documentation of follow-up information in the record.
Client # 10 was admitted on January 16, 2024 and was discharged on February 13, 2024. There was no documentation of follow-up information in the record.
Client # 11 was admitted on February 7, 2024 and was discharged on March 5, 2024. There was no documentation of follow-up information in the record.
This is a repeat citation from the May 12, 2022 and April 21, 2023 annual licensing renewal inspections.
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 6/21/24 conducted by the Clinical Supervisor regarding this regulation, and how to properly document follow-up in the record using our Follow-Up Contact form.
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 semiannual audits to include all Plans of Correction to ensure full implementation.
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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 and administrative documentation, the facility failed to comply with plans of corrections that were approved by the Department.
A plan of correction for calling client emergency contacts within 12 hours of an Against Staff Advice discharge was submitted and approved by the Department for the April 21, 2023 and May 12, 2022, annual licensing inspections. Contacting emergency contacts was again found to be a deficiency in the May 16, 2024-May 17, 2024 licensing inspection.
A plan of correction for including follow-up information in the client record was submitted and approved by the Department for the April 21, 2023 and May 12, 2022, annual licensing inspections. Completing follow-up information was again found to be a deficiency in the May 16, 2024-May 17, 2024 licensing inspection.
A plan of correction for completing a drug and alcohol support plan in the Short-Term Detoxification level of care was submitted and approved by the Department for the April 21, 2023 and May 12, 2022, annual licensing inspections. Completing a drug and alcohol support plan was again found to be a deficiency in the May 16, 2024-May 17, 2024 licensing inspection.
A plan of correction for ensuring fire drill logs included the exit route used was submitted and approved by the Department for the April 21, 2023 and May 12, 2022, annual licensing inspections. Documenting the exit route used in fire drills was again found to be a deficiency in the May 16, 2024-May 17, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 7/1/24, The Program Director will be responsible for the implementation and compliance of all plans of correction. The Program Director will collect data from past inspections to determine how to avoid repeated citations and the best procedures for implementing new POC. It will be the responsibility of the Program Director and the Division to ensure that future violations are not incurred in this area and that POC are put in place. The Division Director will also ensure POC are followed by meeting with Program Director to audit past and present POC procedures. The Compliance Quality Team will audit the program every quarter to make sure that the program remains in compliance. All data gathered from the monthly and quarterly audits will be recorded. These methods will focus on the proper protocol for completing client consents and releases, other relevant documentation, and POC.
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