INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on June 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:
|
Plan of Correction
|
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
|
Observations
Based on a review of personnel records, the facility failed to provide a written individual training plan for each employee, appropriate to that employee's skill level that documented it was developed annually with input from both the employee and the supervisor in two out of five personnel records reviewed.
Employee #2 was hired as a facility director on May 16, 2016 and was still in that position as of the date of the inspection. The individual training plan had no documentation that the plan was developed with input from both the employee and supervisor and the date completed.
Employee #3 was hired as a clinical supervisor on March 21, 2023 and was still in that position as of the date of the inspection. The individual training plan had no documentation that the plan was developed with input from both the employee and supervisor and the date completed.
Employee #4 was hired as a counselor on April 18, 2022 and was still in that position as of the date of the inspection. The individual training plan had no documentation that the plan was developed with input from both the employee and supervisor and the date completed.
Employee #5 was hired as a counselor on April 26, 2021 and was still in that position as of the date of the inspection. The individual training plan had no documentation that the plan was developed with input from both the employee and supervisor and the date completed.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
Due to revisions made by the corporate training department as it relates to staff individualized training plans, supervisors neglected to obtain a separate staff signature verifying training goals were reviewed. Although new year training needs and goals are discussed in all performance reviews which receives staff signature upon completion, a single training plan verification was not obtained. To correct this issue, all supervisors at Lewisburg will review 2023 staff training needs and goals by July 30th, 2023 and document this process in a supervisory session to be signed by the employee. Going forward, this will be the same process in future years to ensure staff understand and participate in their own training goals. This will be part of the routine annual performance review requirement and will be reviewed for completion by the facility Division Director. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on the review of client records, the facility failed to document a complete psychosocial evaluation within guidelines established by the facility's policy and procedures manual in five out of seven records reviewed. The facility's policy and procedures manual states the psychosocial evaluation must be completed within 30 days of admission.
Client #1 was admitted on May 22, 2023 and was still active at the time of the inspection. There was no documentation that a psychosocial evaluation was completed at the time of the inspection.
Client # 3 was admitted on March 23, 2023 and was still active at the time of the inspection. The psychosocial was due no later than April 23, 2023; however, it was completed on June 7, 2023.
Client # 4 was admitted on January 3, 2023 and was still active at the time of the inspection. The psychosocial was due no later than February 3, 2023; however, it was completed on February 6, 2023.
Client #5 was admitted on July 8, 2022 and was discharged on November 2, 2022. The psychosocial was due no later than August 8, 2022; however, it was completed on October 19, 2023.
Client # 7 was admitted on December 8, 2022 and discharged on February 1, 2023. There was no documentation that a psychosocial evaluation was completed at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
A clinical meeting will be held with staff by July 30th, 2023 to address treatment management procedures specific to completion of the biopsychosocial upon initial session. All clinical staff will be directed to complete the biopsychosocial at intake. In order to address all requirements during the initial session, all intake sessions will be extended in time to ensure priority is given to completing all applicable requirements of the client history. All clients reviewed during this cite visit, as long as still active at the program, will have their biopsychosocial completed by July 30th, 2023. The Division Director/supervisor will complete monthly audit reviews to ensure biopsychosocial histories are completed for each client. The CQI team as well as the Corporate Outpatient Director will in turn, complete their quarterly audits to address compliancy. The QA Managers as well as the Corporate Outpatient Director will complete quarterly chart audits to ensure compliance. Any issues noted will be documented in a Performance Improvement Plan to be addressed with clinicians and corrected within 48 hours. |
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:
|
Observations
Based on a review of client records, the facility failed to document a comprehensive treatment plan within guidelines established by the facility's policy and procedures manual in four out of seven records reviewed. The facility's policy and procedures manual states the comprehensive treatment plan must be completed within 30 days of admission.
Client #2 was admitted on April 7, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than May 7, 2023; however, was completed on May 9, 2023.
Client # 3 was admitted on March 23, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than April 23, 2023; however, was completed on May 2, 2023.
Client #4 was admitted on January 3, 2023 and still active at the time of the inspection. A comprehensive treatment plan was due no later than February 3, 2023; however, was completed on February 6, 2023.
Client #7 was admitted on December 8, 2022 and was discharged on February 1, 2023. A comprehensive treatment plan was due no later than January 8, 2023; however, there was no documentation that one was completed.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
A clinical meeting will be held with staff by July 30th, 2023 to address treatment management procedures specific to completion of the client comprehensive treatment plan to be done with the client within 30 days of admission into treatment. All clinical staff will be directed to complete the comprehensive treatment plan with the client prior to the 30th day. Staff will be reminded that comprehensive treatment plans can always be done early when the client is present. Comprehensive treatment plans will be completed no later than July 30th, 2023 for those clients identified who are still active in treatment. The Division Director/Supervisor will conduct monthly chart audits to ensure comprehensive treatment plans are being completed within the 30 day time frame. Clinical staff documentation will be monitored monthly in regular supervisory sessions. The QA Managers as well as the Corporate Outpatient Director will complete quarterly chart audits to ensure compliance. Any issues noted will be documented in a Performance Improvement Plan to be addressed with clinicians and corrected within 48 hours. |
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.
|
Observations
Based on the review of client records, the facility failed to document a discharge summary within guidelines established by the facility's policy and procedures manual in two out of three applicable client records. The facility's policy and procedures manual states the discharge summary is completed at the time of discharge.
Client #5 was admitted on July 8, 2022 and was discharged on November 2, 2022. There is no documentation that a discharge summary was completed at the time of the inspection.
Client #7 was admitted on December 8, 2022 and was discharged on February 1, 2023. The discharge summary was completed on May 1, 2023.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
A clinical meeting will be held with staff by July 30th, 2023 to address treatment management procedures specific to continuing care/transition/discharge plan. Clinical staff will be reminded that the discharge plan must be completed within 72 hours of a client's discharge from treatment. The Division Director/supervisor will review for compliance during the monthly internal CQI audit process. Additionally, quarterly audits will be completed by the Regional QA Manager as well the Corporate Outpatient Director. All audit results are documented monthly via SharePoint and results are reviewed with staff during monthly supervisory sessions. |
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.
|
Observations
Based on the review of client records, the facility failed to document follow up information within guidelines established by the facility's policy and procedures manual in two out of three applicable client records. The facility's policy and procedures manual states the follow up contact should be completed within thirty days of discharge if no aftercare appointments were scheduled.
Client #6 was admitted on July 19, 2022 and discharged on March 7, 2023. A follow up contact was not completed until May 1, 2023.
Client # 7 was admitted on December 8, 2022 and discharged on February 1, 2023. A follow up contact was not completed until May 1, 2023.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
A clinical meeting will be held with staff by July 30th, 2023 to address treatment management procedures specific to client follow up after discharge. Staff will be reminded that for those clients referred to another program or service, upon receiving written client consent, a follow up phone call will occur within 7 days of discharge/referral. For all other types of discharges (ASA, completion, non ? compliance) a follow up phone call will be done within 30 days of client discharge. All follow up will be completed by the onsite Certified Recovery Specialist or other assigned staff. The Division Director/supervisor will review for compliance during the monthly internal CQI audit process using a standard tool which lists follow up as an item. Additionally, quarterly audits will be completed by the Regional QA Manager as well the Corporate Outpatient Director. All audit results are documented monthly via SharePoint and results are reviewed with staff during monthly supervisory sessions. Follow up reminders have been added in the electronic health record "My To Do List" for staff assigned. |