INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 22, 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, 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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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection on May 22, 2023, between 10:15 a.m. and 11:30 a.m., the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. A group session in the first group room on the right hallway could be heard outside of the group room while in the room next doorThese findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will ensure that when Group Room #2 is in use, no one is allowed access to Group room #1 and vice versa. In addition, a sound machine will be placed in the main hallway during group sessions.
Counselors will ensure that the sound machines are operable and running prior to beginning group sessions.
Program Director will also monitor use of sound machines during group sessions for ongoing compliance. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill logs from May 2022 through April 2023, the facility failed to prepare alternate exit routes as the same exit route was documented in each drill.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will ensure that alternate exit routes are used for monthly fire drills.
The CQI Manager will perform a quarterly inspection of completed fire drill logs.
The Division Director will review the requirement with the Program Director during a supervision session. |
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 seven 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 #6 was admitted on December 13, 2022 and was active at the time of the inspection. The record contained a client signed consent to release information form to the funding source on January 3, 2023; however, the record contained evidence of billing prior to the client signing the consent form.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counselors will ensure that a signed consent is obtained from each client enrolled on the day of admission.
The Program Director will conduct monthly clinical chart audits to include a review of signed consent forms to ensure that they are completed according to prescribed time frames.
The Div. Director will conduct bi-monthly clinical chart audits.
The CQI Manager will conduct quarterly quantitative and qualitative clinical chart audits and will review open plans of correction at each review. |
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 ensure that an individual treatment and rehabilitation plan was developed with the client within 30 days of the preliminary treatment plan, per the facility policy, in two of six applicable records reviewed. Client #4 was admitted on July 11, 2022 and was discharged October 18, 2022. The preliminary treatment plan was completed on July 11, 2022 and the individual treatment and rehabilitation plan was due to be completed by August 11, 2022; however, it was not completed until September 20, 2022.Client #6 was admitted on December 13, 2022 and was active at the time of the inspection. The preliminary treatment plan was completed on December 13, 2022 and the individual treatment and rehabilitation plan was due to be completed by January 13, 2023; however, it was not completed until January 24, 2023.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will run the Treatment Plan Analysis Report weekly to track upcoming treatment plans.
The Program Director will conduct monthly clinical chart audits to include a review of services provided according to treatment plans.
The Div. Director will conduct bi-monthly clinical chart audits.
The CQI Manager will conduct quarterly quantitative and qualitative clinical chart audits and will review open plans of correction at each review. |
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 ensure a complete client record included information relative to the client's involvement with the project to include case consultation information quarterly, in four of five applicable records reviewed. Client #1 was admitted on April 4, 2022 and was discharged on February 13, 2023. The first case consultation documentation was due to be completed by July 4, 2022; however, it was not completed until September 12, 2022. The next case consultation was due to be completed by December 12, 2022; however, it was not completed until January 5, 2023. Client #4 was admitted on July 11, 2022 and was discharged October 18, 2022. There was no documentation of case consultation information in the record.Client #5 was admitted on August 24, 2022 and was active at the time of the inspection. The first case consultation was completed on November 14, 2022 and the next case consultation was due to be completed by February 14, 2023; however, it was not completed until April 11, 2023. Client #6 was admitted on December 13, 2022 and was active at the time of the inspection. There was no documentation of case consultation information in the record.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counselors will begin using the Notes to Self-widget in Avatar NX to track upcoming case consultations.
The Program Director will run the Notes Audit Report weekly to keep monitor the completion of case consultations.
Counselors will route completed Case Consultations to all participating parties for signature before submitting to the Program Director for signature and approval.
The Program Director will conduct comprehensive clinical chart audits to include a review of completed case consultations.
The Div. Director will conduct bi-monthly clinical chart audits.
The CQI Manager will conduct quarterly quantitative and qualitative clinical chart audits and will reassess the program's adherence to this Plan of Correction at the next review. |