INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 12, 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 West Shore 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, the facility failed to ensure that one of four applicable counselors met the education and experience requirement for the position.
Employee #6 was hired as a counselor on August 23, 2022 and was still current in that position at the time of the inspection. Employee #6 has a qualifying bachelor ' s degree but does not have the one year of required clinical experience.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective July 7th, 2023, the employee that did not meet counselor requirements has been transitioned into a Counselor Assistant role and will be provided weekly non-direct supervision until she meets the one year of clinical experience that is required for someone who has a qualifying bachelor's degree.
Moving forward to ensure this does not happen again, resumes will be reviewed by Corporate Outpatient Director prior to offer being made for an open position. The Division Director and the Corporate Outpatient Director will review in detail the qualifications and the resume. |
709.28 (c) (4) 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. The consent must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of seven client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the signature of the client in one record reviewed.
Client #7 was admitted January 11, 2023 and was still current at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information to a significant other dated March 10, 2023, did not include the client ' s signature.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Members of the West Shore OP team will attend a Release/Request of Information training on July 21st, 2023. This training will be facilitated by our Director of Quality Assurance. The review will include that client's signature must be on every release of information completed. Ongoing monitoring will occur through monthly chart audits that are completed by the Division Director as well as quarterly chart audits completed by CQI Manager. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination in two out of two applicable records reviewed.
Client #2 was admitted on May 27, 2022 and discharged on August 5, 2022.
Client #3 was admitted on November 30, 2022 and discharged on December 20, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical meeting scheduled for July 12th, 2023 will include review of policy that when a decision has been made to involuntarily terminate an individual's treatment that the client will receive notice in writing and that it will include the reason. The Division Director will also review the form in the agency's Electronic Health Record. Ongoing chart compliance will continue to be completed monthly by the Division Director and quarterly by the CQI manager. For the first 3 months following the meeting on July 12th, 2023, the Division Director will document compliance for discharged clients whose treatment was terminated. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of seven client records, the facility failed to develop an individual treatment and rehabilitation plan with three clients reviewed.
Client #2 was admitted on May 27, 2022 and discharged on August 5, 2022. An individual treatment and rehabilitation plan dated June 15, 2022 did not indicate the plan was developed with the client as the signature said " COVID 19 signature. "
Client #4 was admitted on December 14, 2022 and was still current at the time of the inspection. The individual treatment and rehabilitation plan dated April 25, 2023 had " unavailable " written on the signature line.
Client #7 was admitted January 11, 2023 and was still current at the time of the inspection. An individual treatment and rehabilitation plan dated February 10, 2023 did not indicate the plan was developed with the client as the signature said " COVID 19 signature. "
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Meeting scheduled for July 12th, 2023 will include review of treatment plan policies. The Division Director will specifically discuss that the development of a treatment plan must be done with the client. The review will also include documenting in the individual progress note that the development of the treatment plan occurred, if the client is participating in the service via telehealth. Ongoing chart compliance will continue monthly by the Division Director and quarterly by the CQI manager. For the first 3 months following the July 12th, 2023 meeting, the review will include looking at timely developed treatment plans as well as accurate documentation regarding the development of the plan with the client. |
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 client records, the facility failed review and update treatment and rehabilitation plans at least every 60 days in two out of six applicable records reviewed.
Client #4 was admitted on December 14, 2022 and was still current at the time of the inspection. An initial treatment and rehabilitation plan was developed on December 13, 2022, and the next was due by February 13, 2023; however, the next documented treatment plan was not until April 25, 2023.
Client #5 was admitted on February 24, 2023 and was still current at the time of the inspection. An initial treatment and rehabilitation plan was developed on February 28, 2023, and the next was due no later than April 28, 2023; however, there was no documentation of any other treatment plans.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An additional widget has been added to the Electronic Health Record as of June 28th, 2023. This widget allows clinical staff to review the due date of treatment plans for each of the clients on their caseload. The clinical team was notified verbally of this update on June 28th, 2023 by the Division Director.
Ongoing, the Division Director will print out and distribute the Treatment Plan Analysis Report each week for the clinicians and continued monitoring for success will occur during monthly and quarterly chart audits completed by the Division Director and CQI Manager. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. 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 assure that counseling services are provided according to the individual treatment and rehabilitation plan in two out of four applicable records.
Client #2 was admitted on May 27, 2022 and discharged on August 5, 2022. A treatment and rehabilitation plan dated July 13, 2022 indicated individual sessions biweekly and group three times a week. There was no documentation of individual sessions after July 8, 2023 in the client record.
Client #7 was admitted January 11, 2023 and was still current at the time of the inspection. A treatment and rehabilitation plan dated March 24, 2023 indicated individual sessions biweekly and group sessions twice a week. The last group session documented was on April 27, 2023 until the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A clinical meeting is scheduled for July 12th, 2023 for the clinicians at West Shore Office. A review of treatment plans will be completed by the Division Director and this will include reminding staff that frequency of internal services must be accurate. The clinical team will also be scheduled to attend the Treatment Plan Training that is facilitated by Corporate OP Director in August, date to be determined.
Ongoing monitoring will occur by Division Director as treatment plans are routed to her for signature. Any inaccuracy will result in a rejection of approval, asking that corrections be made and sent back for approval/signature. |
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 client records, the facility failed to document case consultation notes in four out of six applicable records reviewed. The facility ' s policy is to complete case consultations quarterly.
Client #2 was admitted on May 27, 2022 and discharged on August 5, 2022.
Client #3 was admitted on November 30, 2022 and discharged on December 20, 2022.
Client #6 was admitted on October 10, 2022 and was still current at the time of he inspection.
Client #7 was admitted January 11, 2023 and was still current at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During clinical meeting on July 12th, 2023, the clinical team at West Shore will be shown how to use/read the Clinical Forms Audit that is available in our Electronic Health Record by the Division Director. This form was created to assist counselors in monitoring due dates of required forms throughout a client's treatment stay.
During this training, Division Director will also print out the form for each current client, to assist the counselors in getting organized. Ongoing monitoring will occur with monthly and quarterly chart audits completed by both the Division Director and the CQI Manager. |
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 client records, the facility failed to have a complete client record on an individual which includes information relative to the client ' s involvement with the project including a discharge summary in one out of three applicable records.
Client #3 was admitted on November 30, 2022 and discharged on December 20, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Division Director will review the required documents needed for discharges during clinical meeting on July 12th, 2023.
Beginning July 2023, in addition to active client chart audits, the Division Director will audit all closed charts within that month for compliance with discharge summaries. This will be ongoing for three months, ending at the end of September. The CQI manager has also committed to 10% of their chart audits being discharged clients ongoing. Adherence to this request will occur during the quarterly CQI chart audit review meetings by the Division Director. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to have a complete client record on an individual which includes information relative to the client ' s involvement with the project including follow up information in two out of three applicable records. The facility ' s policy requires a follow up contact note within seven days of an aftercare appointment or within thirty days of discharge.
Client #1 was admitted on September 26, 2022 and discharged on February 23, 2023.
Client #3 was admitted on November 30, 2022 and discharged on December 20, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On June 30th, 2023, the Division Director has set up a meeting with the Administrative Assistant at West Shore to discuss completing follow up contact notes starting July 1st 2023. The meeting will include demonstrating using the new widget that has been added to the Electronic Health Record that lists the follow ups that are needed.
Division Director will monitor success of this transition ongoing by not only reviewing the completion of the follow up contact note during monthly chart audits, but also by reviewing the report "Details of Discharge" on a weekly basis that shows completion of follow up contact notes for the next 2 months, ending August 31st, 2023. |