INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 5, 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 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)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of CPR cards and discussion with Facility Director, the facility failed to ensure that at least one person trained in CPR is onsite during the project ' s hours of operation.
The facility failed to ensure that the following shifts had CPR coverage:
3pm-11pm shift on the dates for March 2021:3/14, 3/16, 3/17, 3/18, 3/19, 3/21, 3/22, 3/26, 3/28, 3/29, 3/31.
8:30am-4:30pm shift on the dates of March 2021: 3/13, 3/18, 3/20, 3/21, 3/22, 3/24, 3/27.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
704.11(c)(2) LICENSURE
CPR CERTIFICATION:
704.11. Staff development program. (c) General training requirements. (2) CPR certification and first aid training. As of 05/20/2022, All Serenity staff have attended a CPR / First Aid training and now are all certified.
A new tracking system for trainings has been developed and topic has been added to the monthly staff meeting agenda, so that training needs are closely monitored by the Program Director nd Coordinator, as well as the staff member, themselves.
Therefore; all staff within the facility will be CPR and First Aid Certified, on all shifts. |
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.
Gaudenzia 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.
Completion date: 9/30/2022
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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 the review of seven client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in one client record reviewed.
Client #3 was admitted on January 27, 2022 and was still an active client at the time of the inspection. There was documentation that a report was made to the fundings source on April 15 and 29, 2022; however, there was no informed and voluntary consent to release information form signed by the client prior to disclosure.
These findings were reviewed with the project staff during the licensing process.
This is a repeat citation from an annual licensing inspection conduced on April 22, 2021.
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Plan of Correction
In accordance with 709.28 (c) confidentiality: The client is question was admitted on 01/27/2022, with CCBH Insurance; which a consent was obtained. However, the client changed her insurance to PerformCare, Dauphin County's MCO between the end of March, beginning of April, 2022.
Unfortunately, her counselor overlooked not having a PerformCare consent, as consents for funding / insurance because generally this completed by administrative employee's. A new consent for perform care was not generated by client's primary counselor, as she had been on vacation during licensing and returned the day, client 3 was being discharged.
To ensure current / proper consents are in place, the Program Director will monitor and review our internal EHR system at minimum, 2 times weekly. Any disparities, changes or additions to consents / releases will be discussed weekly, in clinical meeting and will be changed or corrected; by either the primary counselor or administrative coordinator.
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709.51(b)(7) LICENSURE Preliminary Tx. Plan.
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of seven client records, the facility failed to document a preliminary treatment plan in three client records reviewed.
Client #1 was admitted on November 19, 2021 and was still active at the time of the inspection. There was no documentation of a preliminary treatment plan in the client record.
Client #2 was admitted on December 29, 2021 and was still active at the time of the inspection. There was no documentation of a preliminary treatment plan in the client record.
Client #3 was admitted on January 27, 2022 and was still active at the time of the inspection. There was no documentation of a preliminary treatment plan in the client record.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In accordance with 709.51 (b)(7) Licensure Preliminary Treatment Plans. Out of the seven charts reviewed, three individuals did not have a preliminary Treatment Plans; Admission Dates: 11/19/21, 12/29/21, 01/27/22.
During the referenced time period, Serenity House was without (2) counselor's until 02/07/22.
Prior to February 7th, 2022, The Program Director was attempting to fulfill open counselor position, in addition to a few other roles, within the facility.
On February 7th, 2022, a counselor from another facility transferred permanently to Serenity House. Since then, clinical services and documentation have increased and are timely.
On 05/09/22, Weekly Clinical Supervision began. Cases are discussed and processed, by the clinical team. Weekly EHR reports are generated and used as a tracking system, so preliminary treatment plans are completed within the required time frame.
The program director will be responsible for running the report and following up with clinical staff to ensure, the preliminary treatment plans are complete. In the event of another staffing crisis, program director or other clinical staff will complete the preliminary plan. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. 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 complete comprehensive treatment plans in three client records reviewed.
Client #1 was admitted on November 19, 2021 and was still active at the time of the inspection. The client's comprehensive treatment plan was not completed at the time of the inspection.
Client #2 was admitted on December 29, 2021 and was still active at the time of the inspection. The client's comprehensive treatment plan was not completed at the time of the inspection.
Client #3 was admitted on January 27, 2021 and was still active at the time of the inspection. The client's comprehensive treatment plan was not completed at the time of the inspection.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
In accordance with regulation 709.52 (a) Licensure Individual Tx. and Rehab Plan; Of the (7) files reviewed, (3) files were in in compliance. Client's admitted on 11/19 and 12/29/2021, in addition to client admitted on 01/27/2022, did not have a comprehensive treatment plan.
At the time of inspection. As previously stated; the facility's program director was an acting counselor, in addition to several other unoccupied positions, due to staff shortage.
On February 7th, 2022, a counselor was permanently transferred from another facility, filling the vacancy. Since then, we have started weekly clinical meetings, in which the program director and (2) counselor's meet to go over; client progress, chart deficiencies, funding and further clinical referrals, etc.
The Program Director will run our internal EHR clinical report; weekly, to ensure that clinical services and documentation are meeting regulatory guidelines.
The program director will discuss current and future documentation needs at the Clinical supervision meeting, weekly.
In the event, of a future staffing shortage, the program director or clinical delegate will complete the documentation, in accordance with regulatory standards. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 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 3 of 3 applicable client records reviewed.
Client #5 was admitted on July 28, 2021 and was discharged on March 27, 2022. A comprehensive treatment plan was completed July 28, 2021, and the next update was due no later than September 28, 2021; however, there was no update documented in the record until February 14, 2022.
Client #6 was admitted on June 21, 2021 and was discharged on February 26, 2022. A treatment plan update was completed October 19, 2021, and the next update was due no later than December 19, 2021; however, there was no update documented in the record at the time of the inspection.
Client #7 was admitted on June 1, 2021 and was discharged on January 14, 2022. A treatment plan updated was completed on June 8, 2021, and the next update was due no later than August 8, 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.
This is a repeat citation from an annual licensing inspection conduced on April 22, 2021.
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Plan of Correction
In accordance with regulatory section 709.52 (b) Licensure TX Plan updates: The facility failed to meet regulatory compliance, for (3) out of (7) records reviewed for updated Tx. Plans.
Client 5, client 6 and client 7, all of which were admitted, prior to February 7th, 2022, during a staff shortage, were late to receive their updated treatment plans, as the facility program director was an acting counselor in addition to several other open positions.
On February 7th, 2022, the facility acquired another counselor, which has helped significantly to improve clinical services and documentation.
As of 05/09/22, weekly clinical supervision is held; in which clinical deficits, tx plans / needs and or goals, future referrals and funding are discussed.
The program director will generate the EHR report; "Clinical Scorecard Report", at minimum 2 times per week. The finding in the report will be shared in the clinical supervision meeting, held weekly.
The program director or clinical delegate will complete the documentation, in accordance with state regulatory criteria, in the event of a staffing shortage or the absence of the responsible, clinical staff. |
709.53(a)(8) LICENSURE Case Consultation Notes
709.53. 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 policy and procedure manual and seven client records, the facility failed to complete and document at least one case consultation every 90 days in all seven client records reviewed.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In accordance with 709.53 (a) (8) Licensure Case Consultation notes: The facility failed to complete and document at least (1) case consultation, every (90) days.
On May 9th, 2022, the program director began weekly clinical supervision. Clinical deficiencies are discussed and corrected, as well as conducting case consultation between the clinical team. The program director is able to run clinical reports daily, in our EHR system; which provides current and future dates and documentation needed.
Since 05/09/22, late and or missing clinical documentation has decreased. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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 seven 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 that included follow up information in three of three applicable client records reviewed.
Client #5 was admitted on July 28, 2021 and was discharged on March 27, 2022. There was no documentation of follow up information being completed in the client record.
Client #6 was admitted on June 21, 2021 and was discharged on February 26, 2022. There was not documentation of follow up information being completed in the client record.
Client #7 was admitted on June 1, 2021 and discharged on January 14, 2022. There was no documentation of follow up information being completed in the client record.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
In accordance with regulatory section 709.53 (a) (11) follow up information and documentation. The facility failed to obtain / document follow up information and documentation on (3) of (3) client records, reviewed.
Since the onset of the weekly clinical supervision meetings on May 9th, 2022, follow up calls; information and documentation have begun with every discharged client. The Administrative Coordinator is now responsible for making the follow-up calls and documenting them. Agency wide, our EHR system was adapted to included the tracking ability for follow-up calls. This addition has assisted us in monitoring follow-ups more closely and getting them completed on time, in accordance with regulations.
Follow-up calls will be monitored weekly by the Program Director and Administrative Coordinator.
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709.53(a)(12) LICENSURE Work as treatment
709.53. 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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of seven client records, the facility failed to ensure that all work done by the client at the project is an integral part of the treatment and rehabilitation plan in three of three client records reviewed.
Client #5 was admitted on July 28, 2021 and was discharged on March 27, 2022. There was no documentation in the client ' s treatment plan that all work done by the client at the project is an integral part of the treatment and rehabilitation plan
Client #6 was admitted on June 21, 2021 and was discharged on February 26, 2022. There was no documentation in the client ' s treatment plan that all work done by the client at the project is an integral part of the treatment and rehabilitation plan
Client #7 was admitted on June 1, 2021 and was discharged on January 14, 2022. There was no documentation in the client ' s treatment plan that all work done by the client at the project is an integral part of the treatment and rehabilitation plan
These findings were discussed with facility staff during the licensing process.
This is a repeat citation from an annual licensing inspection conduced on April 22, 2021.
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Plan of Correction
709.53(a)(12) LICENSURE
Work as treatment: The facility failed to document (7) out of (7) client records: that all work done by the client at the project is an integral part of their treatment and rehabilitation plan. This item will be reviewed as needed, during weekly, clinical supervision. The inclusion of this goal and language will be listed on every clients treatment plan, as an ongoing goal until discharge, from the facility.
The program director and clinicians will review and edit, on a weekly bases, during clinical supervision. |