INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 14, 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 five personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that one employee received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #5 was hired as a counselor assistant on July 8, 2019 and was due to have the communicable disease trainings no later than July 8, 2020. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Employee # 5 attended HIV/Aids on May 7, 2021 as well as TB/STD's on 2-13-20 however, due to clinical failure to follow training tracking processes, a copy of the certificate was not present for the inspection. The 2-13-20 certificate is now on site and in employee # 5's personnel chart. Staffing training requirements has been added to the monthly management meeting agenda and will be reviewed by the Clinical Supervisor and Program Director for ongoing compliance. |
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 seven client records, the facility failed to document treatment plan updates within the regulatory timeframe in three client records reviewed.
Client #1 was admitted on June 22, 2020 and was still active at the time of the inspection. A treatment plan update was completed on November 23, 2020 and the next update was due no later than January 23, 2021; however, there was no update documented in the record until March 15, 2021.
Client #2 was admitted on May 7, 2020 and was still active at the time of the inspection. A treatment plan update was completed on December 4, 2020 and the next update was due no later than February 4, 2021; however, there was no update documented in the record until March 12, 2021.
Client #4 was admitted on November 20, 2020 and was still active at the time of the inspection. A treatment plan update was completed on December 10, 2020 and the next update was due no later than February 10, 2021; however, there was no update documented in the record at the time of the inspection.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
An all staff in service meeting will be held on May 21, 2021 to address clinical staff on treatment management procedures specific to the treatment plan update process. All staff will be directed to update treatment plans every 60 days or sooner. Should the client fail to attend the scheduled session to develop treatment plans as due, clinical staff will proceed and document that the plan will be reviewed with the client during the next attended session. The Clinical Supervisor & Program Director will review treatment plans for compliancy during the CQI process monthly. Clinical staff will be monitored monthly in regular supervisory sessions. |
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 seven outpatient client records, there was no documentation that the clients received counseling services according to their individual comprehensive treatment plan in four records reviewed.
Client #1 was admitted on June 22, 2020 and was still active at the time of the inspection. The treatment plan, dated March 15, 2021, indicated one group session per week and one individual session per week. The client ' s record of service and progress notes indicated that the client had received no group sessions since March 15, 2021.
Client #2 was admitted on May 7, 2020 and was still active at the time of the inspection. The treatment plan, dated October 9, 2020, indicated one group session per week and one individual session per week. The client ' s record of service and progress notes indicated that the client had received no group sessions since November 29, 2020.
Client #3 was admitted on July 29, 2020 and was still active at the time of the inspection. The treatment plan, dated March 26, 2021, indicated one group session per week and one individual session per week. The client ' s record of service and progress notes indicated that the client had received no group sessions or individual sessions since April 29th, 2021.
Client #4 was admitted on November 20, 2020 and was still active at the time of the inspection. The treatment plan, dated December 10, 2020, indicated one group session per week and one individual session per week. The client ' s record of service and progress notes indicated that the client had received no group sessions since starting treatment.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
An all staff in service meeting will be held on May 21, 2021 to address staff on treatment management procedures specific to assuring that counseling services are provided according to the individual and treatment plan updates. All staff will be directed to schedule clients according to their treatment recommendation and document weekly on the client record of service. Any deviation from the set course of treatment will also be documented on the note. Clinicians will attempt to reengage clients and discuss the recommended treatment course. This discussion will be documented in an independent or individual progress note. If the client refuses to commit or follow through with recommendations a new treatment plan will be developed and services will be adjusted accordingly. The Clinical Supervisor and Program Director will review treatment plan recommendations and compare it to the record of service for compliance during the CQI process monthly. Clinical staff will be monitored monthly in regular supervisory sessions as well as bi weekly during clinical meeting. |
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 complete and document follow up information in two of three applicable records reviewed.
Client #5 was admitted September 15, 2020 and discharged December 3, 2020.
Client #7 was admitted December 31, 2020 and was discharged March 16, 2021.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
An all staff meeting will be held on May 21, 2021 to address clinical staff on treatment management procedures specific to assuring that follow up is to be completed for every type of discharge. Management staff reviewed the most efficient process and determined that the follow up will be completed by the assigned clinical staff and submitted as part of the discharge documentation process. The Clinical Supervisor and Program Director will review for compliance during the monthly internal CQI process. Clinical staff will be monitored monthly in regular supervisory sessions. Additionally, the Regional Quality Assurance department will conduct quarterly audits to ensure compliance; this audit will be documented in the quarterly CQI report. The compliance department will conduct annual reviews to ensure continued implementation of all action items on the corrective action plan. |