INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 25-26, 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-Coal Township 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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705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical site inspection on May 25, 2022, the facility failed to keep the grounds clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors.
The step to the outside recreational area was crumbling, causing a tripping hazard.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
A maintenance request has been submitted for the repair to the step on 6/10/2022.
In the meantime, this door will not be used on a day-to-day basis, in order to avoid the potential trip hazard. The nearby side door will be utilized instead, and a sign placed on this door to this effect.
We expect to have repairs completed no later than 7/31/22.
Safe egress as well as all safety concerns are monitored on a monthly basis with a walk-through documented on a safety report. The Program Director will review the report each month and ensure that any issues identified are addressed immediately.
The Quality Assurance department will conduct at least quarterly reviews of the program, to include a physical plant inspection, and review of all plans of correction to ensure full implementation. Any issues identified will be noted in a report and a performance improvement plan developed with the program. |
705.5 (a) (1) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(a) In each residential facility bedroom, each resident shall have the following:
(1) A bed with solid foundation and fire retardant mattress in good repair.
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Observations
Based on a physical site inspection on May 25, 2022, the facility failed to have bed with a solid foundation and fire-retardant mattress in good repair in each bedroom.
Vinyl mattresses in bedrooms 2, 5, 7, 9, 14, 17 and 18 were peeling and falling apart.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
All mattresses in the building will be replaced no later than 7/31/22. This plan was already in motion, along with a number of other furniture and physical plant upgrades.
The condition of the beds is monitored on a monthly basis with a walk-through documented on a safety report. The Program Director will review the report each month and ensure that any issues identified are addressed immediately.
The Quality Assurance department will conduct at least quarterly reviews of the program, to include a physical plant inspection, and review of all plans of correction to ensure full implementation. Any issues identified will be noted in a report and a performance improvement plan developed with the program. |
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. |
709.53(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 seven client records, the project failed to include case consultation notes in two of three applicable records reviewed.
Client #13 was admitted on March 30, 2022 and discharged on April 9, 2022. Client #13 did not have a case consultation documented in their record at the time of the inspection.
Client #14 was admitted on April 22, 2022 and discharged on May 4, 2022. Client #14 did not have a case consultation documented in their record at the time of the inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Case consultation notes will be documented according to Gaudenzia documentation workflow at 15 days. If an individual leaves the program prior to that point, and it is possible to convene a treatment team meeting to discuss the situation, a case consultation will be documented in the electronic health record using the Case Consultation form.
This was reviewed with all clinical staff on 6/6/22 and 6/7/22, which was documented with a sign-in sheet.
The Clinical Supervisor will send a reminder to clinicians at the beginning of each month noting which clients are due for case consultations. Calendars are being utilized to keep close track of time-sensitive dates for each client. Upcoming case consultations will also be reviewed in weekly Clinical Staff meeting.
The Clinical Supervisor will conduct monthly audits of a sample of charts in order to ensure that case consultations 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 bi-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. |
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 in one of three applicable clients that included information relative to the client's involvement with the project, including follow-up information.
Client #14 was admitted on April 22, 2022 and was discharged on May 4, 2022. Client #14 did not have documentation of follow-up information in the client record.
These findings were reviewed with project staff during the licensing process.
This was a repeat citation from an inspection that took place on May 10, 2021.
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Plan of Correction
A follow-up contact was completed for this individual on 6/9/22, and documented using the Follow-Up Contact Note in the electronic health record.
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.
This will be the responsibility of the Administrative Coordinator at the program. This will be done by running a discharge report from our electronic health record each day, and noting which clients require a follow-up contact.
Staff were re-trained in in-service trainings on 6/6/22 and 6/7/22 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 Administrative Coordinator will send a reminder to clinicians at the beginning of each week noting which clients are due for follow-up. Calendars are being utilized to keep close track of time-sensitive dates for each client. Upcoming follow-ups will be reviewed in daily Clinical Staff meeting.
The Clinical Supervisor will conduct monthly 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 bi-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 client records, the facility failed to verify that work done by the clients at the project is an integral part of their treatment and rehabilitation plan in three out of seven client records reviewed.
Client # 8 was admitted on March 23, 2022 and was still current at the time of the inspection. Client #8 did not have a work goal in their treatment plans dated March 23, 2022, March 24, 2022, April 8, 2022, or May 8, 2022.
Client # 10 was admitted on March 26, 2022 and was still current at the time of the inspection. Client #10 did not have a work goal in their treatment plans dated March 27, 2022, March 28, 2022, or April 10, 2022.
Client # 14 was admitted on April 22, 2022 and was discharged on May 4, 2022. Client #14 did not have a work goal in their treatment plans dated April 23, 2022, or May 3, 2022.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
This was the responsibility of one counselor. This was addressed in a documented supervision session. The treatment plan for the one client still active in the program will be updated no later than 6/10/22.
Staff were re-trained in in-service trainings on 6/6/22 and 6/7/22 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 monthly 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 and Deputy Regional Director will conduct bi-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. |