INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 3, 2021 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(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report, the project failed to ensure that employee #4 received the minimum of four hours of TB/STD and other health related topics within the regulatory timeframe.Employee #4 was hired as a counselor on April 22, 2019 and was due to have the communicable disease trainings no later than April 22, 2020. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Employee #4 has been registered for the required training and will complete it by 03/05/21.
Training records are reviewed by the Clinical Supervisor on a monthly basis to ensure compliance.
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705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plan inspection conducted on February 3, 2021, the facility failed to ensure that the hot water temperature not exceed 120 degrees Fahrenheit. Upon testing the temperature of the water in the client's bathroom sink, it was found that the water temperature registered at 131.5 degrees Fahrenheit.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A request was forwarded to building management on 02/17/21 to have the water temperature adjusted to <120 degrees. The Project anticipates repair by 03/05/21.
The Clinical Supervisor will monitor the water temperature on a monthly basis to ensure compliance. |
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 the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in two of seven client records reviewed.Client #3 was admitted on September 3, 2020 and was discharged December 18, 2020. There was evidence that the project billed the funding source for services provided; however, there was no release of information form for the funding source documented in the record prior to the disclosure.Client #7 was admitted on October 14, 2020 and was a current client at the time of the inspection. There was evidence that the project billed the funding source for services provided; however, there was no release of information form for the funding source documented in the record prior to the disclosure.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Clinical Supervisor will meet with all clinical staff to review the confidentiality policy and PHI consents by 03/05/21. In addition, the Clinical Supervisor will audit files on a monthly basis to ensure compliance. Items found to be out of compliance will be reviewed with the respective clinical staff during regular supervision. CQI will conduct quarterly file audits to ensure compliance. CQI audit findings will be shared with Program Management and reviewed during CQI meetings. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the project failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in five of seven client records reviewed.Client #1 was admitted on September 21, 2020 and was discharged on November 3, 2020. A release of information form to a funding source, signed and dated by a witness on September 21, 202, allowed for the release of psychological and psychiatric evaluations, treatment plans, case consults, mental health records, physical and medical records, discharge summary, progress notes, medication records and assessments, all of which exceeds the limits established by 4 Pa. Code 255.5. Additionally, a release of information form to a child welfare agency, signed and dated by a witness on September 17, 2020, allowed for the release of psychological and psychiatric evaluations, treatment plans, mental health records, physical and medical records, discharge summary, progress notes, medication records and assessments.Client #2 was admitted on September 21, 2020 and was discharged on November 30, 2020. A release of information form to a funding source, signed and dated by a witness on September 21, 202, allowed for the release of psychological and psychiatric evaluations, treatment plans, case consults, mental health records, physical and medical records, discharge summary, progress notes, medication records and assessments, all of which exceeds the limits established by 4 Pa. Code 255.5.Client #4 was admitted on September 17, 2020 and was discharged on December 24, 2020. A release of information form to a funding source, signed and dated by a witness on September 17, 202, allowed for the release of psychological and psychiatric evaluations, treatment plans, case consults, mental health records, physical and medical records, discharge summary, progress notes, medication records and assessments, all of which exceeds the limits established by 4 Pa. Code 255.5.Client 5 was admitted on September 9, 2020 and was a current client at the time of the inspection. A release of information form to a funding source, signed and dated by a witness on September 9, 202, allowed for the release of psychological and psychiatric evaluations, treatment plans, case consults, mental health records, physical and medical records, discharge summary, progress notes, medication records and assessments, all of which exceeds the limits established by 4 Pa. Code 255.5.Client #6 was admitted on October 1, 2020 and was a current client at the time of the inspection. Two release of information forms, one to the funding source and the other to a child welfare agency, was signed and dated by a witness on September 25, 2020, allowing for the release of psychological and psychiatric evaluations, physical and medical records, discharge summary and assessments, all of which exceeds the limits established by 4 Pa. Code 255.5.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Release of Information document has been updated to ensure that disclosures of client identifying information is within the limits established by 4 Pa. Code 255.5 (b).
For the two clients listed as active, the Clinical Supervisor will review all Releases of Information in the file and obtained new consents were necessary.
The Clinical Supervisor will meet with all clinical staff to review the confidentiality policy and PHI consents by 03/05/21. In addition, the Clinical Supervisor will audit files on a monthly basis to ensure compliance. Items found to be out of compliance will be reviewed with the respective clinical staff during regular supervision. CQI will conduct quarterly file audits to ensure compliance. CQI audit findings will be shared with Program Management and reviewed during CQI meetings.
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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 the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included a dated client signature in six of seven client records reviewed.Client #1 was admitted on September 21, 2020 and was discharged on November 3, 2020. Three release of information forms, one to the funding source, the second to a laboratory and the third to a child welfare agency, were signed and dated by a witness on September 21, 2020; however, all three release of information forms did not have a dated client signature. Client #2 was admitted on September 21, 2020 and was discharged on November 30, 2020. Two release of information forms, one to the funding source and the second to a laboratory, were signed and dated by a witness on September 21, 2020; however, both release of information forms did not have a dated client signature. Client #4 was admitted on September 17, 2020 and was discharged on December 24, 2020. Two release of information forms, one to the funding source and the second to a laboratory, were signed and dated by a witness on September 17, 2020; however, both release of information forms did not have a dated client signature. Client 5 was admitted on September 9, 2020 and was a current client at the time of the inspection. Three release of information forms, one to the funding source, the second to a laboratory and the third to court officials, were signed and dated by a witness on September 9, 2020; however, all three release of information forms did not have a dated client signature. Client #6 was admitted on October 1, 2020 and was a current client at the time of the inspection. Three release of information forms, one to the funding source, the second to a laboratory and the third to a child welfare agency, were signed and dated by a witness on September 25, 2020; however, all three release of information forms did not have a dated client signature. Client #7 was admitted on October 14, 2020 and was a current client at the time of the inspection. A release of information form to a laboratory, was signed and dated by a witness on October 14, 2020; however, the release of information forms did not have a dated client signature. These findings were reviewed with project staff during the licensing process.This is a repeat citation from last year's licensure renewal inspection.
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Plan of Correction
Last review period, in an effort to ensure that a "dated client signature" was obtained on consents for the disclosure of information, the Covid-19 Policy and Procedure was revised by the Continuous Quality Assurance Department to indicate how the project would attempt to obtain signatures on consent to release forms, which included obtaining "verbal consents" due to COVID-19. Staff were also trained on the process. Counseling Staff attempted to schedule at least one face-to-face meeting with all clients for orientation. During this meeting Counseling staff attempted to obtain the necessary signatures for consents and releases. Unfortunately, due to COVID-19, some clients were only able to give verbal consent.
Gaudenzia has recently implemented the use of DocuSign as a means to remotely obtain required signatures on critical clinical documentation. Staff have been trained on DocuSign on January 26th with a follow up which occurred on February 2nd. This is now fully implemented. Clinical Supervisor end program Director will conduct audits of a sample of clinical charts on a weekly basis in order to ensure compliance. The QA team will conduct program reviews including chart audits on a quarterly basis. The compliance team will conduct audits at least annually of corrective action plans in order to ensure implementation.
Three of the clients listed have already discharged from services. The Clinical Supervisor has reached out to all other active clients to have them complete new releases of information. |
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 the review of client records, the project failed to document an individual treatment and rehabilitation plan or that an individual treatment and rehabilitation plan was developed with a client in two of seven client records reviewed.Client #1 was admitted on September 21, 2020 and was discharged on November 3, 2020. A comprehensive treatment and rehabilitation plan was completed on September 22, 2020; however, there was no documentation of an individual session on that date and that the treatment plan was completed with the client. Client #3 was admitted on September 3, 2020 and was discharged on December 18, 2020. A comprehensive treatment and rehabilitation plan was not documented for the client.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Clinical Supervisor will meet with all clinical staff to review the treatment plan policy by 03/05/21. In addition, the Clinical Supervisor will audit files on a monthly basis to ensure compliance. Items found to be out of compliance will be reviewed with the respective clinical staff during regular supervision. CQI will conduct quarterly file audits to ensure compliance. CQI audit findings will be shared with Program Management and reviewed during CQI meetings. |
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 the review of client records, the project failed to document that the treatment and rehabilitation plan was reviewed and updated at least every 60-days in two of seven client records reviewedClient #2 was admitted on September 21, 2020 and was discharged on November 30, 2020. A comprehensive treatment and rehabilitation plan was completed on September 21, 2020 and the next treatment plan update was due no later than November 21, 2020; however, there was no treatment and rehabilitation plan update documented in the record at the time of the inspection. Client #4 was admitted on September 17, 2020 and was discharged on December 24, 2020. A comprehensive treatment and rehabilitation plan was completed on September 17, 2020 and the next treatment plan update was due no later than November 17, 2020; however, there was no treatment and rehabilitation plan update documented in the record at the time of the inspection.These findings were reviewed with project staff during the licensing process.This is a repeat citation from last year's licensure renewal inspection.
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Plan of Correction
During the last review period, the Clinical Supervisor conducted a staff in-service on 10/09/2020 to provide technical assistance to Counseling staff regarding Treatment Plan updates and the timely completion of Treatment Plans.
The Clinical Supervisor also conducted monthly audits of active files to ensure that Treatment Plans are updated every 60 days. The Clinical Director reviewed findings with staff during supervisions.
The Clinical Supervisor will meet with all clinical staff to review the treatment plan policy by 03/05/21. In addition, the Clinical Supervisor will implement a tracking tool for clinicians that will assist them with tracking dates for treatment plan updates. In addition, the Clinical Supervisor will audit files on a monthly basis to ensure compliance. Items found to be out of compliance will be reviewed with the respective clinical staff during regular supervision. CQI will conduct quarterly file audits to ensure compliance. CQI audit findings will be shared with Program Management and reviewed during CQI meetings.
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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 the review of client records, the project failed to document a complete client record on an individual's involvement with the project that included case consolation notes in four of seven client records reviewed.Client #3 was admitted on September 3, 2020 and was discharged on December 18, 2020. There were no case consultation notes documented in the client record.Client #4 was admitted on September 17, 2020 and was discharged on December 24, 2020. There were no case consultation notes documented in the client record.Client 5 was admitted on September 9, 2020 and was a current client at the time of the inspection. There were no case consultation notes documented in the client record.Client #6 was admitted on October 1, 2020 and was a current client at the time of the inspection. There were no case consultation notes documented in the client record.These findings were reviewed with project staff during the licensing process.This is a repeat citation from last year's licensure renewal inspection.
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Plan of Correction
During the last review period, the Clinical Supervisor conducted monthly audits of active files to ensure that Case Consults are Conducted in accordance with policy. The Clinical Director reviewed these audits with the Counseling Staff during supervision.
Clinical Supervisor will continue to meet with clinical staff and will conduct a training on Case Consultations with all clinical staff to review the case consultation policy by 03/05/21. In addition, the Clinical Supervisor will implement a tracking tool to assist clinical staff with calculating due dates for case consultations. The Clinical Supervisor will also continue to audit files on a monthly basis to ensure compliance. Items found to be out of compliance will be reviewed with the respective clinical staff during regular supervision. CQI will conduct quarterly file audits to ensure compliance. CQI audit findings will be shared with Program Management and reviewed during CQI meetings.
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