INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 16, 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 Montgomery County Outpatient 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 on March 29, 2021 and was due to have the communicable disease trainings no later than March 29, 2022. However, 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.The findings were discussed with facility staff during the licensing process.
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Plan of Correction
This staff member completed the TB/STD training on 5/27/22 and will be scheduled to attend the next DDAP-approved HIV/AIDS training in June. Program Director will follow up with staff member to ensure that this training is completed as scheduled.
Going forward, the Program Director will review training plans for all staff members on at least a quarterly basis. Any staff members who are approaching deadlines will be scheduled to complete all required trainings prior to the required timeframe. The first of these reviews will be completed by 6/30/22
The Quality Assurance Department will conduct at least quarterly reviews of all programs, to include a review of all plans of correction to ensure full implementation.
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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.
Chief Financial Officer 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. 9/30/22
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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 thirteen records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in five records reviewed. Additionally, the facility failed to keep disclosures of client identifying information within the limits established by Pa Code 255.5 (b) in one record reviewed.Client #1 was admitted to the Outpatient activity on September 3, 2021 and was discharged on March 16, 2022. The record contained documentation that an evaluation with detailed personal, mental health, and substance use histories, was sent to a probation officer, which exceeded the limits established in Pa Code 255.5(b).Client #2 was admitted to the Outpatient activity on December 9, 2021 and was discharged on February 2, 2022. The record did not contain a client signed consent to release information form to the funding source and there was evidence of billing.Client #4 was admitted to the Outpatient activity on November 13, 2020 and discharged on February 17, 2022. The record did not contain a client signed consent to release information form to the funding source from May 16, 2021 through February 17, 2022 and there was evidence of billing during that time period.Client #6 was admitted to the Outpatient activity on July 29, 2021 and was active at the time of the inspection. The record did not contain a client signed consent to release information form to the funding source and there was evidence of billing.Client #11 was admitted to the Intake, Evaluation, and Referral activity on August 9, 2021. The record contained documentation that the client was referred to an outside treatment provider on August 9, 2022, to whom the record did not contain a client signed consent to release information form.Client #12 was admitted to the Intake, Evaluation, and Referral activity on October 8, 2021. The record contained documentation that the client was referred to an outside treatment provider on October 8, 2021, to whom the record did not contain a client signed consent to release information form.This is a repeat citation from the June 30, 2021 annual licensing inspection.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The majority of these confidentiality issues were the responsibility of two staff member who are no longer with the organization. All current staff members with responsibility for completion of releases will attend the DDAP web-based Drug and Alcohol Confidentiality Training delivered by DDAP. This will be completed by 6/30/22.
The Clinical Supervisor will complete at least bi-weekly audits of a sample of charts including a qualitative review of consent forms to ensure that all information to be released is within the established limits. Any issues noted will be brought to the immediate attention of the clinician and corrected within 48 hours.
The Program Director will conduct at least monthly audits of the charts will bring any issues noted to the attention of the Clinical Supervisor to be addressed with the clinician and corrected within 48 hours. The Division Director will complete at least quarterly audits.
The Quality Assurance department will conduct quarterly audits which will result in a Performance Improvement Plan developed in collaboration with program management to address any issues identified.
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709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of thirteen records, the facility failed to ensure that an informed and voluntary consent to disclose information form included the name of the person, agency, or organization to whom disclosure is made in one record reviewed.Client #3 was admitted on August 27, 2021 and was active at the time of the inspection. The record contained a consent to release information form signed by the client on August 27, 2021, that was missing a specific name, agency, or organization.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All current staff members with responsibility for completion of releases will attend the DDAP web-based Drug and Alcohol Confidentiality Training delivered by DDAP. This will be completed by 6/30/22.
The Clinical Supervisor will complete at least bi-weekly audits of a sample of charts including a qualitative review of consent forms to ensure that all consent forms include to whom information is to be released. Any issues noted will be brought to the immediate attention of the clinician and corrected within 48 hours.
The Program Director will conduct at least monthly audits of the charts will bring any issues noted to the attention of the Clinical Supervisor to be addressed with the clinician and corrected within 48 hours. The Division Director will complete at least quarterly audits.
The Quality Assurance department will conduct quarterly audits which will result in a Performance Improvement Plan developed in collaboration with program management to address any issues identified.
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709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of unusual incident reports provided by the facility, the facility failed to ensure that events at the facility requiring the presence of police, fire, or ambulance personnel were reported to the Department within three business days. Police were onsite on December 8, 2021, however, the incident was not reported to the Department as of the date of the inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This unusual incident was since sent to DDAP on 5/17/22.
Our internal incident reporting system has been updated to include an email prompt alerting the Program Director that an incident may need to be reported to DDAP with a link to the DDAP ERS portal.
The Program Director will also review all incident submissions and reference the DDAP regulations regarding unusual incident reporting to ensure that any incident meeting the criteria is reported.
The Quality Assurance department also conducts at least quarterly programs reviews which include a review of incident logs. Any issues noted will result in a Performance Improvement Plan developed in collaboration with program management to address any issues identified.
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709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of six client records, the facility failed to ensure that individual treatment and rehabilitation plans included documentation of the proposed type of support services in three records reviewed.Client # 1 was admitted on September 3, 2021 and discharged on March 16, 2022. The individual treatment and rehabilitation plan signed by the client on October 4, 2021 did not include the proposed type of support services.Client # 3 was admitted on August 27, 2021 and was active at the time of the inspection. The individual treatment and rehabilitation plan signed by the client on October 21, 2021 did not include the proposed type of support services.Client # 7 was admitted on February 28, 2022 and was active at the time of the inspection. The individual treatment and rehabilitation plan signed by the client on April 7, 2022 did not include the proposed type of support services.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All Treatment plans will document external support services offered. If an individual refuses any external support services, this will be documented in a clinical note.
This expectation will be reviewed with all clinical staff in an in-service no later than 6/17/22 conducted by the Clinical Supervisor. This training will include specific examples of the types of external support services available to be offered to the client, and how to document refusal of these services.
The Clinical Supervisor will conduct weekly audits of a sample of charts in order to ensure that treatment plans include documentation of external support services offered for all charts (or a note specifying why not). Any missing documentation will be brought to the attention of the clinician and completed within 48 hours.
The Program Director will conduct 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.
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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 a review of the facility's written plan for the coordination of client treatment and rehabilitation services, the facility's written procedures for the management of treatment/rehabilitation services for clients indicated that staff names and titles would be included as part of case consultation documentation. Five of five applicable records reviewed did not indicate that any staff participated in the case consultations.Client #1 was admitted on September 3, 2021 and was discharged on March 16, 2022. The client record did not contain documentation of case consultation notes that included the names and titles of participants.Client #3 was admitted on August 27, 2021 and was active at the time of the inspection. The client record did not contain documentation of case consultation notes that included the names and titles of participants.Client #4 was admitted on November 13, 2020 and was discharged on February 17, 2022. The client record did not contain documentation of case consultation notes that included the names and titles of participants.Client #5 was admitted on December 6, 2021 and was active at the time of the inspection. The client record did not contain documentation of case consultation notes that included the names and titles of participants.Client #6 was admitted on July 29, 2021 and was active at the time of the inspection. The client record did not contain documentation of case consultation notes that included the names and titles of participants.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will be re-trained in an in-service no later than 6/17/22 conducted by the Clinical Supervisor regarding how to route case consults in our electronic health record to all who participated to obtain their signatures.
The Clinical Supervisor will conduct weekly audits of a sample of charts in order to ensure that all case consults are signed by all in attendance. Any missing signatures will be brought to the attention of the clinician and completed within 48 hours.
The Program Director will conduct monthly audits of a sample of charts. Any missing signatures 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.
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