INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 20, 2023, through April 21, 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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705.10 (c) (2) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(2) Maintain at least one portable fire extinguisher with a minimum of an ABC rating in each kitchen.
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Observations
Based on a physical plant inspection on April 21, 2023, the facility failed to ensure that the kitchen maintain at least one portable fire extinguisher with a minimum of an ABC rating.
This is a repeat citation from the May 12, 2022 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The ABC fire extinguisher has been ordered and installed in the kitchen on 5/10/2023. Fire Extinguishers are inspected at least monthly by facility staff which is documented on the fire Extinguisher tags and in the safety report. The Program Director will review the safety report each month to ensure compliance.
As of 5/18/22, a K class fire extinguisher has been installed in addition to the ABC class fire extinguisher.
In addition, fire extinguishers are monitored by the QA Department during quarterly CQI site inspections and any findings will be reported to the Program Director for immediate action. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of six personnel records, the facility failed to ensure that each staff was instructed in the use of the fire extinguishers upon employment in two records reviewed.
Employee #4 was hired as a counselor on February 21, 2023 and was due to be trained in the use of fire extinguishers upon employment; however, fire safety training was not documented as complete until March 30, 2023.
Employee #5 was hired as a support staff member on February 27, 2023 and was due to be trained in the use of fire extinguishers upon employment; however, fire safety training was not documented as complete until March 30, 2023.
This is a repeat citation from the May 12, 2022 annual licensing inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, The Program Director and Administrative Coordinator will ensure that all new hires receive the required fire safety training within the first 7 days of employment. This will be done by reviewing all new hire requirements with each new employee at the end of their first 5 days of employment. Any staff who have not yet had the training at that point will receive it immediately. This will be completed in our Relias web-based training system during their orientation period. This will be documented in the staff file and the individual training plan through Relias for each employee.
In addition, training files are monitored by the QA Department during quarterly CQI reviews, and any findings will be reported to the Program Director for immediate action. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of fire drill logs from July 2022 through April 2023, the facility failed to ensure that fire drill logs included the exit route used for each fire drill conducted.
This is a repeat citation from the May 12, 2022 annual licensing inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, the Program Director will ensure that all documentation of fire drills note the exit route used. The Program Director will review all fire drill documentation following each drill, and will have staff make any necessary corrections/additions immediately.
The Quality Assurance Department will conduct at least quarterly audits to include a review of fire drill logs using an auditing tool which includes this as a specific item. Any issues noted will be brought to the immediate attention of the Program Director and will be included on a performance improvement plan. This had been noted by our QA Manager in a review on 4/20/2023 and subsequent fire drills have been documented correctly. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of fourteen client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients in one of two applicable records reviewed.
Client #8 was admitted to Residential Rehabilitation level of care on June 25, 2022 and discharged Against Facility Advice (AFA) on June 27, 2022. The facility failed to follow their policy related to AFA discharges of calling the Emergency Contact within twelve hours.
This is a repeat citation from the May 12, 2022 annual licensing inspection.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
Notification will be made to the Emergency Contact person for any client leaving the program against staff advice. This is the responsibility of the Primary Counselor for each respective client. If the Primary Counselor is not present, then the Clinical Supervisor will notify the Emergency Contact.
The Clinical Supervisor and Program Director will review the policy again with all staff in an in-service training no later than 6/9/2023 with all clinical staff.
The Clinical Supervisor will review all client files at time of discharge to ensure that this has been completed. Any chart missing this notification will be brought to the attention of the clinician to make immediate notification to the documented emergency contact.
The Program Director will conduct at least monthly chart audits using our quantitative audit tool, which lists this as a specific item for review.
The Program director will run the Clinical Forms audit report at least 3x/week to monitor documentation compliance.
The QA Manager will conduct at least quarterly audits to include monitoring of this requirement. Any issues noted will be brought to the attention of the Clinical Supervisor and Program Director for immediate correction. |
709.34 (c) (1) 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:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on a review of client records and the unusual incident logbook, the project failed to file a written unusual incident report with the Department within three business days following an unusual incident involving the physical or sexual assault by staff or a client.
There was documentation of a patient assault on August 23, 2022; however, there was no documentation that written unusual incident report was filed with the Department.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Any and all instances of physical assault will be reported to DDAP per regulations. As of 5/24/23, Program Director and staff have reviewed the DDAP 709.34 regulations, and now understand this requirement. The Program Director will review all incident reports and will ensure that any unusual incidents are reported per regs.
As for the incident report submission, it was submitted to DDAP on 4/24/2023.
The QA Manager will conduct at least quarterly audits to include monitoring of this requirement. Any issues noted will be brought to the attention of the Program Director for immediate correction. |
709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records and the facility ' s policies and procedure manual, the facility failed to document a psychosocial evaluation, within 72 hours of admission as per policy, in two of six applicable records reviewed.
Client #1 was admitted on February 27, 2023 and was discharged on March 3, 2023. The record did not contain a psychosocial evaluation.
Client #6 was admitted on April 16, 2023 and was active at the time of the inspection. The record did not contain a psychosocial evaluation.
These finding were discussed with facility staff during the licensing process.
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Plan of Correction
A Psychosocial Evaluation will be completed for all clients within the required timeframes as specified in our policies and procedures, including clinical workflows.
The Clinical Supervisor and Program Director will review the policy again with all staff in an in-service training no later than 6/9/2023 with all clinical staff.
The Clinical Supervisor will review all client files within 7 days of admission to ensure that this has been completed. Any chart missing this documentation will be brought to the attention of the clinician to make immediate corrections.
The Program Director will conduct at least monthly chart audits using our quantitative audit tool, which lists this as a specific item for review.
Program director will run the Clinical Forms audit report at least 3x/week to monitor documentation compliance.
The QA Manager will conduct at least quarterly audits to include monitoring of this requirement. Any issues noted will be brought to the attention of the Clinical Supervisor and Program Director for immediate correction.
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709.63(a)(2) LICENSURE D & A support plan
709.63. 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:
(2) Drug and alcohol support plan.
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Observations
Based on a review of seven client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include a drug and alcohol support plan completed within 24 hours, which is the policy of the project, in three of seven records reviewed.
Client #1 was admitted on February 27, 2023 and was discharged on March 3, 2023. The drug and alcohol support plan was due to be completed by February 28, 2023; however, it was not completed until March 2, 2023.
Client #4 was admitted on February 8, 2023 and discharged on February 13, 2023. The drug and alcohol support plan was due to be completed by February 9, 2023; however, it was not completed prior to the client ' s discharge.
Client #6 was admitted on April 16, 2023 and was active at the time of the inspection. The drug and alcohol support plan was due to be completed by April 17, 2023; however, it was not completed prior to the inspection.
This is a repeat citation from the May 12, 2022 annual licensing inspection.
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 6/9/23 conducted by the Clinical Supervisor regarding this requirement, and how to properly document this in the record.
The Clinical Supervisor will send a daily reminder to clinicians at the beginning of each morning to discuss which clients are due for Drug and Alcohol Support Plans. Clinical staff will route all Drug and Alcohol Support Plans to the Clinical Supervisor for approval. Calendars are being utilized to keep close track of time-sensitive dates for each client.
The Clinical Supervisor will conduct weekly audits of a sample of charts using our quantitative audit tool to ensure that timely Drug and Alcohol Support Plans are completed for all charts. 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 to ensure that timely Drug and Alcohol Support Plans are completed for all charts. Any missing documentation will be brought to the attention of the Clinical Supervisor to follow up with the clinician in supervision and completed within 48 hours.
The QA Manager will conduct at least quarterly audits to include monitoring of this requirement. Any issues noted will be brought to the attention of the Clinical Supervisor and Program Director for immediate correction.
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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 client records and the facility ' s policies and procedure manual, the facility failed to document a preliminary treatment and rehabilitation plan, within 72 hours of admission as per facility policy, in one of two applicable records reviewed.
Client #14 was admitted on March 21, 2023 and was active at the time of the inspection. The preliminary treatment plan was not completed until April 10, 2023.
These finding were discussed 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 6/9/23 conducted by the Clinical Supervisor regarding this requirement, and how to properly document this in the record.
Clinical staff will route all Preliminary Plans to the Clinical Supervisor for approval. Calendars are being utilized to keep close track of time-sensitive dates for each client.
The Clinical Supervisor will conduct weekly audits of a sample of charts using our quantitative audit tool to ensure that timely Preliminary Plans are completed for all charts. Any missing documentation will be brought to the attention of the clinician and completed within 48 hours.
The Program director will run the Clinical Forms audit report at least 3x/week to monitor documentation compliance.
The Program Director will conduct monthly audits of a sample of charts to ensure that timely Preliminary Plans are completed for all charts. Any missing documentation will be brought to the attention of the Clinical Supervisor to follow up with the clinician in supervision and completed within 48 hours.
The QA Manager will conduct at least quarterly audits to include monitoring of this requirement. Any issues noted will be brought to the attention of the Clinical Supervisor and Program Director for immediate correction.
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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 two of five applicable records reviewed.
Client #10 was admitted on February 13, 2023 and was discharged on March 10, 2023. The individual treatment and rehabilitation plan was completed on February 18, 2023, and the treatment plan update was due no later than March 4, 2023; however, the update was not completed until March 13, 2023.
Client #12 was admitted on March 25, 2023 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed while in a higher level of care at the facility on March 22, 2023, and the treatment plan update was due no later than April 5, 2023; 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
Staff will be re-trained in an in-service no later than 6/9/23 conducted by the Clinical Supervisor regarding this requirement, and how to properly document this in the record.
Clinical staff will route all Treatment Plan updates to the Clinical Supervisor for approval. Calendars are being utilized to keep close track of time-sensitive dates for each client.
The Clinical Supervisor will conduct weekly audits of a sample of charts using our quantitative audit tool to ensure that timely Treatment Plan updates are completed for all charts. 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 to ensure that timely Treatment Plan updates are completed for all charts. Any missing documentation will be brought to the attention of the Clinical Supervisor to follow up with the clinician in supervision and completed within 48 hours.
The Program director will run the Clinical Forms audit report at least 3x/week to monitor documentation compliance.
The QA Manager will conduct at least quarterly audits to include monitoring of this requirement. Any issues noted will be brought to the attention of the Clinical Supervisor and Program Director for immediate correction. |
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 client records, the facility failed to follow their written client follow-up policy in two of four applicable records reviewed. The facility ' s policies and procedures indicate that if the client is referred to another program, then Gaudenzia will contact the program within seven days of the referral appointment.
Client #9 was admitted on September 27, 2022 and was discharged on October 25, 2022. The facility failed to follow up with the referral treatment provider within seven days of the client's discharge.
Client #10 was admitted on February 13, 2023 and was discharged on March 10, 2023. The facility failed to follow up with the referral treatment provider within seven days of the client's discharge.
This is a repeat citation from the May 12, 2022 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clients will be contacted post-discharge and this contact (or attempt) will be documented in our electronic health record on the Follow Up Contact Note created for this purpose. This will occur within 7 days of the date of the referral appointment for completions, and within 30 days for all other discharges.
When a client is discharged after being referred to another facility, the facility will be contacted within 7 days of the date of appointment at the facility.
The newly created Care Coordinator position will be responsible for this function. This will be done by running a discharge report from our electronic health record each day, and noting which clients require a follow-up contact.
Staff will be re-trained in an in-service no later than 6/9/23 conducted by the Clinical Supervisor regarding this regulation, and how to properly document follow-up in the record using our Follow-Up Contact form.
An internal tracking tool for each chart has been developed to help remind staff of upcoming documentation requirements. This includes follow-up post-discharge. The Clinical Supervisor will send a reminder to clinicians at the beginning of each month noting which clients are due for follow-up. Clinical staff will send all treatment plans to Clinical Supervisor for approval. Calendars are being utilized to keep close track of time-sensitive dates for each client. Upcoming follow-ups will be reviewed in daily Clinical Staff meeting.
The Clinical Supervisor will conduct weekly audits of a sample of charts to ensure that follow-ups are completed for all discharged charts. 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 discharged charts. Any missing documentation will be brought to the attention of the Clinical Supervisor to follow up with the clinician in supervision and completed within 48 hours.
The Program director will run the Clinical Forms audit report at least 3x/week to monitor documentation compliance.
The QA Manager will conduct at least quarterly audits to include monitoring of this requirement. Any issues noted will be brought to the attention of the Program Director for immediate correction. |