INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 24, 2024, 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. Fulton 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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709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records, the facility failed to ensure that annual written individual staff performance evaluations, were reviewed and signed by the employee per the facility ' s policy and procedure manual in two out of three personnel records reviewed. The facility ' s policy and procedure manual states that the annual job performance evaluations are due at the beginning of each calendar year. Project staff indicated evaluations specifically are to be completed and signed by February 1 each year.Employee #1 was hired on September 9, 2019 as the project director and is still in that position at the time of the inspection The annual work performance evaluation was not completed until February 28, 2024. Employee #2 was hired on July 8, 2015 as the facility director and is still in that position at the time of the inspection. The annual work performance evaluation was not completed until February 4, 2024. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
By May 24, 2024, Division Director will speak to the Clinical Supervisors at all programs to let them know the expectation is to review the annual reviews with all staff one week prior to 1/31/25. The Division Director will further review the expectation is after they are discussed with the staff, to have the staff immediately sign into their ADP to sign off on their review and write any applicable comments. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of the client records, the facility failed to document that a copy of a client consent was offered to the client and a copy maintained in the client record in one out of seven client records reviewed. Client #5 was admitted on November 6, 2023 and discharged on February 2, 2024. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated November 6, 2023 were offered to the client. This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
By May 24, 2024, Clinical Supervisor will review the Workflow with all members of the clinical team to ensure that the required consent forms are being completed at time of evaluation and admission to the program. Clinical Supervisor will also review the need to complete consent form for any new entities as needed throughout the clients treatment experience with all clinicians. Overview of the required consent forms will then be a part of the routine monthly chart audit review process conducted by Clinical Supervisor. |
709.91(b)(7) LICENSURE Intake and admission
709.91. 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, the facility failed to document a preliminary treatment plan within the timeframe established by the facility ' s policy and procedures in three out of seven records reviewed. The facility's policy and procedures manual states that the preliminary treatment plan must be completed at the intake. Client #2 was admitted on February 1, 2024 and was still active at the time of the inspection. The preliminary treatment plan was due on February 1, 2024; however, it was not completed until February 15, 2024. Client #5 was admitted on November 6, 2023 and discharged on February 2, 2024. The preliminary treatment plan was due on November 6, 2024; however, there is no documentation that one was completed. Client #6 was admitted on October 17, 2023 and discharged on April 17, 2024. The preliminary treatment plan was due on October 17, 2023; however, it was not completed until October 23, 2023.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By May 24, 2024, Clinical Supervisor will review the Workflow with all members of the clinical team to ensure that the Preliminary Tx Plan is being completed at time of intake/admission to the program. Overview of the required Preliminary Tx Plan will then be a part of the routine monthly chart audit review process conducted by Clinical Supervisor. |
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 a review of the client records, the facility failed to document an individual treatment and rehabilitation plan was developed with the client within guidelines established by the facility ' s policy and procedures manual in five out of five applicable records reviewed. The facility ' s policy and procedures manual states the comprehensive treatment plan must be completed within 30 days of admission. Client #1 was admitted on July 21, 2023 and was still active at the time of the inspection. The comprehensive treatment plan was due no later than August 21, 2023; however, it was not completed until August 23, 2023 and did not have documentation that it was developed with the client. Client #2 was admitted on February 1, 2024 and was still active at the time of the inspection. The comprehensive treatment plan was due no later than March 1, 2024; however, it was not completed until March 21, 2024. Client #3 was admitted on November 8, 2023 and was still active at the time of the inspection. The comprehensive treatment plan was due no later than December 8, 2023; however, it was not completed until December 12, 2023 and did not have documentation that it was developed with the client. Client #6 was admitted on October 17, 2023 and discharged on April 17, 2024. The comprehensive treatment plan was due no later than November 17, 2023; however, it was not completed until November 28, 2023. Client #7 was admitted on August 1, 2023 and discharged on January 18, 2024. The comprehensive treatment plan was due no later than September 1, 2023; however, it was not completed until October 24, 2023.This is a repeat citation from the June 6, 2023 licensing inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Starting May 24, 2024, the Clinical Supervisor will run the treatment plan analysis report on a weekly basis and send emails out to counselors of treatment plans that are due or coming due. Clinical Supervisor is responsible with making sure these are completed by the counselors. Failure by counselors to complete these treatment plans in a timely fashion will result in disciplinary action. |
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 client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in five out of five applicable records reviewed.Client #1 was admitted on July 21, 2023 and was still active at the time of the inspection. The treatment plan dated March 27, 2024 indicated individual counseling weekly. There was no documentation of the client receiving individual counseling the week of April 8, 2024. Client #2 was admitted on February 1, 2024 and was still active at the time of the inspection. The treatment plan dated March 21, 2024 indicated individual counseling weekly. There was no documentation that the client received individual therapy the week of April 1, 2024. Client #3 was admitted on November 8, 2023 and was still active at the time of the inspection. The treatment plan dated January 10, 2024 indicated individual counseling sessions weekly. There was no documentation that the client received individual counseling the weeks of February 26, March 11, 25 and April 8, 2024. Client #6 was admitted on October 17, 2023 and was discharged on April 17, 2024. The treatment plan dated January 25, 2024 indicated individual counseling sessions weekly. There was no documentation that the client received individual counseling the weeks of February 12, March 11, and April 8, 2024. Client #7 was admitted on August 1, 2023 and discharged on January 18, 2024. The treatment plan dated October 24, 2023 indicated individual counseling sessions weekly. There was no documentation that the client received individual counseling the weeks of November 20, December 4 and 18, 2023. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By May 24, 2024, the Clinical Supervisor will conduct an in-service training during clinical team meeting regarding the frequency of individual sessions and how this should be reflected accurately on the treatment plan. Documentation of missed sessions will also be reviewed during this in-service training. Overview of the frequency of sessions as identified on comprehensive tx plan and documentation of missed sessions will be a part of the routine monthly chart audit review process conducted by Clinical Supervisor. |
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 facility failed to provide a complete client record on an individual which includes information relative to the client's involvement with the project, including case consultations within the timeframe established by the facility ' s policy and procedure manual in three out of six applicable client records. The facility's policy and procedures manual states case consultations are completed every ninety days unless the client ' s treatment is less than ninety then one is completed. Client #4 was admitted on November 24, 2023 and was discharged on January 26, 2024. A case consultation was to be completed prior to discharge if the client was only in treatment less than 90 days, there is no documentation that one was completed. Client #5 was admitted on November 6, 2023 and discharged on February 2, 2024. A case consultation was to be completed prior to discharge if the client was only in treatment less than 90 days, there is no documentation that one was completed. Client #6 was admitted on October 17, 2023 and discharged on April 17, 2024. A case consultation was due no later January 17, 2024; however, it was not completed until March 21, 2024. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning May 24, 2024, the Clinical Supervisor will run the Clinical Forms Audit report monthly and send out emails to all staff of case consultations coming due. The Clinical Supervisor will ensure that these case consultations are completed. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on the review of client records, the facility failed to provide a complete client record on an individual which includes information relative to the client's involvement with the project, including an aftercare plan within the timeframe established by the facility ' s policy and procedure manual in two out of four applicable client records. The facility's policy and procedures manual states aftercare planning is completed prior to discharge. Client #4 was admitted on November 24, 2023 and was discharge on January 26, 2024. There is no documentation that an aftercare plan was completed. Client #5 was admitted on November 6, 2023 and discharged on February 2, 2024. There is no documentation that an aftercare was completed. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Starting May 24, 2024 Clinical Supervisor will run the discharge analysis report weekly and send emails to counselors of outstanding discharge paperwork. After the staff meeting on May 24th, counselors will be given one hour of paperwork time dedicated to discharge paperwork per week that must be completed. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to provide a complete client record on an individual which includes information relative to the client's involvement with the project, including a discharge summary in three of four applicable records. The facility's policy and procedure manual states that a discharge summary is completed within seven days of discharge.Client #4 was admitted on November 24, 2023 and was discharge on January 26, 2024. A discharge summary was due no later than February 2, 2024; however, there is no documentation that one was completed. Client #5 was admitted on November 6, 2023 and discharged on February 2, 2024. A discharge summary was due no later than February 9, 2024; however, there is no documentation that one was completed. Client #7 was admitted on August 1, 2023 and discharged on January 18, 2024. A discharge summary was due no later than January 25, 2024; however, there is no documentation that one was completed. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Starting May 24, 2024 Clinical Supervisor will run the discharge analysis report weekly and send emails to counselors of outstanding discharge paperwork. After the staff meeting on May 24th, counselors will be given one hour of paperwork time dedicated to discharge paperwork per week that must be completed. |
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 provide a complete client record on an individual which includes information relative to the client's involvement with the project, including a follow up in three of three applicable records. The facility's policy and procedure manual states that a follow up is completed within seven days of discharge.Client #4 was admitted on November 24, 2023 and was discharge on January 26, 2024. A follow up was due no later than February 2, 2024; however, there is no documentation that one was completed. Client #5 was admitted on November 6, 2023 and discharged on February 2, 2024. A follow up was due no later than February 9, 2024; however, there is no documentation that one was completed. Client #7 was admitted on August 1, 2023 and discharged on January 18, 2024. A follow up was due no later than January 25, 2024; however, there is no documentation that one was completed. This is a repeat citation from the June 6, 2023 licensing inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By May 24, 2024 Clinical Supervisor will review the follow up policy and expectations with the clinical team in clinical team meeting. Documentation of the follow up process will also be reviewed in this meeting. Overview of the follow up process will be part of the routine monthly chart audit review process for discharged client charts by the Clinical Supervisor. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department. A plan of correction for completing and documenting follow up information was submitted and approved by the Department for the April 27, 2022, and June 6, 2023 annual licensing inspections. Completing and documenting follow up contacts was again found to be a deficiency in the April 24, 2024, licensing inspection.This is a repeat citation from the June 6, 2023 licensing inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning June 17th, 2024 and occurring on a monthly basis, the Division Director will attend a CQI meeting. On the agenda of the CQI meeting is to review and present that POCs are being followed at the program level. The Division Director will report updates after completing monthly charts prior to the call, for the program as a way to monitor implementation and adherence of the POC. Any deficiencies will be reviewed with Program Director the same day of the meeting and follow through with documentation will be requested. This will continue throughout the year. |