INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 20, 2015 through May 21, 2015 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. 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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709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on a review of client records, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in six of ten records reviewed.
The findings included:
4 Pa. Code states:
Information released to judges, probation or parole officers, insurance company, health or hospital plan or governmental officials, pursuant to paragraphs (1), (2), (4),(7), (8) or subsection (a) of this section, is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following.
(1) Whether the client is or is not in treatment.
(2) Client's prognosis.
(3) The nature of the project.
(4) A brief description of the client's progress.
(5) A short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse.
Ten client records requiring proper releases of information were reviewed on May 20, 2015 through May 21, 2015. The facility failed to stay within the limits imposed by 4 Pa. Code 255.5 (b) in client records, # 1, 4, 6, 7, 9, and 10.
Client #1 was admitted to treatment on May 7, 2015 and was still an active client at time of the inspection. A release of information to the funding source was signed on 05/07/2015 and allowed for the disclosure of the discharge summary and medications, which exceeded 255.5.
Client #4 was admitted to treatment on May 6, 2015 and was still an active client at time of the inspection. A release of information to the funding source was signed on 05/06/2015 and allowed for the disclosure of the discharge summary and medications, which exceeded 255.5.
Client #6 was admitted to treatment on April 24, 2015 and was discharged on May 15, 2015. A release of information to the funding source was signed on 04/24/2015 and allowed for the disclosure of the discharge summary and medications, which exceeded 255.5.
Client #7 was admitted to treatment on April 9, 2015 and was discharged on April 13, 2015. A release of information to the funding source was signed on 04/09/2015 and allowed for the disclosure of the discharge summary and medications, which exceeded 255.5.
Client #9 was admitted to treatment on May 1, 2015 and was discharged on May 13, 2015. A release of information to the funding source was signed on 05/01/2015 and allowed for the disclosure of the discharge summary and medications, which exceeded 255.5.
Client #10 was admitted to treatment on April 8, 2015 and was discharged on May 1, 2015. A release of information to the funding source was signed on 04/02/2015 and allowed for the disclosure of the discharge summary and medications, which exceeded 255.5.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Supervisor and Director in conjunction with CQI Director will provide training via hand outs and verbal instruction to all staff no later than 6/10/15 specific instruction regarding releases of information specifically to those regarding 4 Pa. Code Paragraphs 1, 2, 4, 7, and 8. Specifically information being released to judges, probation or parole officers, insurance company, health or hospital plan or governmental officials. The information included in this training will be specific to the following and their definitions:
(1) Whether the client is or is not in treatment.
(2) Client's prognosis.
(3) The nature of the project.
(4) A brief description of the client's progress.
(5) A short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse.
In regard to the client charts listed during inspection, these releases of information have been rescinded due to their lack of information and being out of compliance as to ensure no breach of confidentiality. The clients listed are now discharged clients and if further information to these entities are needed the client will be asked to return to complete a properly formatted release of information.
For sustained compliance the Program Supervisor in conjunction with CQI Director will develop releases of information that are in compliance with the aforementioned licensing code. Program Director will oversee the project and review releases upon their completion to be no later than 6/10/15.
Program Supervisor for sustained learning and refresher(s) will implement lunch and learn sessions for staff weekly were issues such as those identified in this citation specifically client #s 1, 4, 6, 7, 9 will be discussed monthly and these lunch and learns will start no later than 7/10/15
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709.28(c)(2) 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 shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on the review of client records, the facility failed to ensure that an informed and voluntary consent to release information was obtained in three of ten client records reviewed.
The findings included:
Ten client records requiring complete informed and voluntary consent to release information forms were reviewed on May 20, 2015 through May 21, 2015. The facility failed to ensure that a completed informed and voluntary consent to release information form was obtained, particularly the specific information to be disclosed, in client records, #5, 6, and 8.
Client #5 was admitted to treatment on March 4, 2015 and was discharged on March 13, 2015. There was a release of information to a family member signed and dated on 03/04/2015; however; the release of information did not include the specific information to be released.
Client #6 was admitted to treatment on April 24, 2015 and was discharged on May 15, 2015. There were two separate release of information forms to two different government agencies signed and dated on 05/12/2015, a release of information to another treatment provider signed and dated on 05/12/2015, and a release of information to an attorney signed and dated on 04/29/2015; however; none of the release of information forms included the specific information to be released.
Client #8 was admitted to treatment on March 12, 2015 and was discharged on March 31, 2015. There was a release of information to another treatment provider signed and dated on 03/11/2015; however; the release of information did not include the specific information to be released.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In response to observation 0279, releases of information as identified have been corrected to bring them into compliance as directed. Program Director and Supervisor will ensure compliance by regular chart audits in conjunction with CQI policies and CQI director.
Client #5 was admitted to treatment on March 4, 2015 and was discharged on March 13, 2015. There was a release of information to a family member signed and dated on 03/04/2015; however; the release of information did not include the specific information to be released. Family releases have been adjusted to include specific information to be released and with in the confidentiality guidelines.
Client number 6 had releases to government agency, attorney and another treatment provider did not have specific information listed on the release. All releases have been updated in accordance with specific information as allowed by code, for government agencies, attorney's and other treatment providers. Program Director and Supervisor will continue to monitor releases via the CQI process in conjunction with CQI Director.
Client #8 was admitted with a release of information for another treatment provider however, there was not specific information with in the release. Program Director and Supervisor have corrected the releases for other treatment providers to include needed information. Program Director and Supervisor will continue to monitor releases via the CQI process in conjunction with CQI Director.
In regard to the aforementioned the Program Supervisor has brought all releases up to date as of 6/6/15. A sample of all admissions will be reviewed as active clients and all charts will be reviewed upon discharge starting on 6/6/15.
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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, the facility failed to document a psychosocial evaluation in three of seven client records reviewed.
The findings include:
Ten client records were reviewed on May 20, 2015 through May 21, 2015, seven of which pertained to the detoxification level of care and required documentation of a psychosocial evaluation during the intake process. The facility failed to document a psychosocial evaluation in client records #1, 3, and 7.
Client #1 was admitted into detox treatment on May 7, 2015, completed detox treatment and was transferred to the inpatient level of care on May 12, 2015, and was still an active client as of the date of the on-site inspection. There was no psychosocial evaluation documented in the client record as of the date of the inspection.
Client #3 was admitted into detox treatment on May 14, 2015, completed detox treatment and was transferred to the inpatient level of care on May 19, 2015, and was still an active client as of the date of the on-site inspection. There was no psychosocial evaluation documented in the client record as of the date of the inspection.
Client #7 was admitted into detox treatment on April 09, 2015 and was discharged on April 13, 2015. There was no psychosocial evaluation documented in the client record 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
Clients 1,3,7 did not have psychosocial assessments completed with in the time frames identified in our policy and procedure.
In the cases of clients 1,3,7, biopsychosocials were added as late entries to the client records as of 6/10/15
Staff realignment has been completed to ensure dedicated staff to detoxification clients e.g. detox counselor as to ensure psychosocial time frames are met. Additionally, an excel spreadsheet has been developed for staff to auto populate when psychosocials (along with other required documentation) are due.
Program Director and Supervisor in conjunction with CQI Director will conduct random sampling aduits to ensure compliance with active clients and with all discharge client charts. |
709.63(a) LICENSURE Client record
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:
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Observations
Based on a review of client records, the facility failed to document a complete client record on an individual, which includes a drug and alcohol support plan and a record of services, in seven of seven client records reviewed.
The findings include:
Ten client records were reviewed on May 20, 2015 through May 21, 2015, seven of which pertained to the detoxification activity, requiring a complete client record on an individual. The facility did not provide a complete client record for client records, #1, 3, 6, 7, 8, 9, and 10.
Client #1 was admitted into detox treatment on May 7, 2015 and completed detox treatment and was transferred to the inpatient level of care on May 12, 2015. The facility failed to include documentation of a record of service during the detoxification period of care.
Client #3 was admitted into detox treatment on May 14, 2015 and completed detox treatment and was transferred to the inpatient level of care on May 19, 2015. The facility failed to include documentation of a record of service during the detoxification period of care.
Client #6 was admitted into detox treatment on April 24, 2015 and completed detox treatment and was transferred to the inpatient level of care on April 29, 2015. The facility failed to include documentation of a record of service during the detoxification period of care.
Client #7 was admitted into detox treatment on April 09, 2015 and completed detox treatment and was transferred to the inpatient level of care on April 14, 2015. The facility failed to include documentation of a record of service during the detoxification period of care. Additionally, the facility failed to include a drug and alcohol support plan for the client while in the detox level of care.
Client #8 was admitted into detox treatment on March 12, 2015 and completed detox treatment and was transferred to the inpatient level of care on March 18, 2015. The facility failed to include documentation of a drug and alcohol support plan during the detoxification period of care.
Client #9 was admitted into detox treatment on May 1, 2015 and completed detox treatment and was transferred to the inpatient level of care on May 5, 2015. The facility failed to include documentation of a record of service during the detoxification period of care.
Client #10 was admitted into detox treatment on April 08, 2015 and completed detox treatment and was transferred to the inpatient level of care on April 13, 2015. The facility failed to include documentation of a record of service during the detoxification period of care. Additionally, the facility failed to include a drug and alcohol support plan for the client while in the detox level of care.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client's 1,3,6,7,9,10 did not have in their charts a client record of service.
Program Director and Supervisor have now included a ROC for all clients including detoxification clients. Moving forward we will have a clinical staff member will be dedicated for detoxification clients e.g. detox counselor to ensure compliance with obersvation 1669.
Program Director and Supervisor will perform random sample active client chart audits and every discharge chart will be audited for compliance upon discharge or transfer to the 3B level of care.
Client 7,8,10 Did not have an identified support plan in their charts. Moving forward, detoxification counselor has been identified and allocated to ensure clinical detoxification compliance with this issue and others listed. Program Director and Supervisor will review a random sample of active charts and all charts upon discharge or transfer from detox to 3B.
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709.51(b)(2)(i) LICENSURE Client Orientation to Project
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(i) Project policies.
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Observations
Based on a review of client records, the facility failed to document the client orientation to the project during the intake process in three of nine client records reviewed.
The findings include:
Ten client records were reviewed on May 20, 2015 through May 21, 2015, nine of which required documentation of the client orientation to the project during the intake process. The facility failed to document the client orientation in client records #2, 3, and 4.
Client #2 was admitted into inpatient treatment on April 23, 2015 and was still an active client as of the date of the on-site inspection. There was no client orientation information documented in the client record as of the day of the inspection.
Client #3 was admitted into detox treatment on May 14, 2015 and was transferred to inpatient treatment on May 19, 2014 and was still an active client as of the date of the inspection. There was no client orientation information documented in the client record as of the day of the inspection.
Client #4 was admitted into inpatient treatment on May 6, 2015 and was still an active client as of the date of the inspection. There was no client orientation information documented in the client record as of the day of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clients 2,3,4 were admitted to the facility and there was no documentation that an orientation to the program was conducted.
Clients listed above were provided with orientation however, it was not documented. An orientation sign off sheet has been added to the aforementioned client records.
Moving forward, the Program Director and Supervisor as of 6/16/15 will institute a 'New client' orientation group daily to include all clients admitted to the program to ensure thorough orientations and compliance with Gaudenzia's internal orientation policies. |
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 the review of client records, the facility failed to document preliminary treatment and rehabilitation plans during the intake process in eight of nine client records reviewed.
The findings included:
Ten client records were reviewed on May 20, 2015 through May 21, 2015, nine of which required documentation of a preliminary treatment and rehabilitation plan during the intake process. The facility failed to document a preliminary treatment and rehabilitation plan during intake in client records #1, 2, 3, 4, 5, 6, 8, and 10.
Client #1 was admitted to inpatient treatment on May 12, 2015 and was still active at the time of the on-site inspection. The facility failed to include documentation of the client's preliminary treatment and rehabilitation plan during the intake process.
Client #2 was admitted to inpatient treatment on April 23, 2015 and was still active at the time of the on-site inspection. The facility failed to include documentation of the client's preliminary treatment and rehabilitation plan during the intake process.
Client #3 was admitted to inpatient treatment on May 19, 2015 and was still active at the time of the on-site inspection. The facility failed to include documentation of the client's preliminary treatment and rehabilitation plan during the intake process.
Client #4 was admitted to inpatient treatment on May 6, 2015 and was still active at the time of the on-site inspection. The facility failed to include documentation of the client's preliminary treatment and rehabilitation plan during the intake process.
Client #5 was admitted to inpatient treatment on March 4, 2015 and was discharged on March 13, 2015. The facility failed to include documentation of the client's preliminary treatment and rehabilitation plan during the intake process.
Client #6 was admitted to inpatient treatment on April 29, 2015 and was discharged on May 15, 2015. The facility failed to include documentation of the client's preliminary treatment and rehabilitation plan during the intake process.
Client #8 was admitted to inpatient treatment on March 17, 2015 and was discharged on March 31, 2015. The facility failed to include documentation of the client's preliminary treatment and rehabilitation plan during the intake process.
Client #10 was admitted to inpatient treatment on April 13, 2015 and was discharged on May 1, 2015. The facility failed to include documentation of the client's preliminary treatment and rehabilitation plan during the intake process.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Clients 1,2,3,4,5,6,8 and 10 did not have preliminary treatment plans in their client record.
Client records listed above have had a preliminary treatment plan added to their client records.
Moving forward, the Program Director and Supervisor as of 6/16/15 will ensure all client records have preliminary treatment plans, utilizing randomized chart audits for active client records along with review of all discharged client records. Conversely, Counselors will be given an excel spreadsheet which will be utilized for clinical documentation compliance as a guide to remain in compliance. Lastly, a clinical in-service will be scheduled to be no later than 6/30/15 to review paperwork required and utilization of the excel spreadsheet. |
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 client records, the facility failed to document an individual treatment and rehabilitation plan in three of nine client records reviewed.
The findings include:
Ten client records requiring documentation of a preliminary treatment and rehabilitation plan were reviewed on May 20, 2015 through May 21, 2015, nine of which pertain to the inpatient level of care. The facility failed to document an individual treatment and rehabilitation plans in client records #1, 3, and 5.
Client #1 was admitted into inpatient treatment on May 12, 2015 and was still an active client as of the date of the on-site inspection. There was no individual treatment and rehabilitation plan documented in the client record as of the date of the inspection.
Client #3 was admitted into inpatient treatment on May 19, 2015 and was still an active client as of the date of the on-site inspection. There was no individual treatment and rehabilitation plan documented in the client record as of the date of the inspection.
Client #5 was admitted into inpatient treatment on March 4, 2015 and was discharged on March 13, 2015. There was no individual treatment and rehabilitation plan documented in the client record 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
3 client records 1,3 and 5 did not contain an individual treatment and rehabilitation plan.
Individual treatment plans have been added to the client records listed above.
Program Director and Supervisor will provide staff with an excel spreadsheet to utilize for clinical documentation to maintain compliance moving forward with all clinical documentation. Also, Program Director and Supervisor will conduct an in-service no later than 6/30/15 to remind staff of clinical documentation guidelines etc. |
709.53(a) LICENSURE Complete Client Record
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:
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Observations
Based on a review of client records, the facility failed to document a complete client record on an individual, which includes a record of service in seven of nine client records reviewed and verification that work being done by the client at the project is an integral part of their treatment and rehabilitation plan in nine of nine client records reviewed.
The findings include:
Ten client records requiring a complete client record on an individual were reviewed on May 20, 2015 through May 21, 2015, nine of which pertained to the inpatient level of care. The facility did not provide a complete client record for client records, #1, 2, 3, 4, 5, 6, 8, 9, and 10.
Client #1 was admitted to inpatient treatment on May 12, 2015 and was still active at the time of the on-site inspection. The facility failed to include documentation of verification that work being done by the client at the project is an integral part of their treatment and rehabilitation plan. Additionally, the facility failed to include documentation of a record of services as of the date of the inspection.
Client #2 was admitted to inpatient treatment on April 23, 2015 and was still active at the time of the on-site inspection. The facility failed to include documentation of verification that work being done by the client at the project is an integral part of their treatment and rehabilitation plan. Additionally, the facility failed to include documentation of a record of services as of the date of the inspection.
Client #3 was admitted to inpatient treatment on May 19, 2015 and was still active at the time of the on-site inspection. The facility failed to include documentation of verification that work being done by the client at the project is an integral part of their treatment and rehabilitation plan. Additionally, the facility failed to include documentation of a record of services as of the date of the inspection.
Client #4 was admitted to inpatient treatment on May 6, 2015 and was still active at the time of the on-site inspection. The facility failed to include documentation of verification that work being done by the client at the project is an integral part of their treatment and rehabilitation plan. Additionally, the facility failed to include documentation of a record of services as of the date of the inspection.
Client #5 was admitted to inpatient treatment on March 4, 2015 and was discharged on March 13, 2015. The facility failed to include documentation of verification that work being done by the client at the project is an integral part of their treatment and rehabilitation plan as of the date of the inspection.
Client #6 was admitted to inpatient treatment on April 29, 2015 and was discharged on May 15, 2015. The facility failed to include documentation of verification that work being done by the client at the project is an integral part of their treatment and rehabilitation plan. Additionally, the facility failed to include documentation of a record of services as of the date of the inspection.
Client #8 was admitted to inpatient treatment on March 17, 2015 and was discharged on March 31, 2015. The facility failed to include documentation of verification that work being done by the client at the project is an integral part of their treatment and rehabilitation plan as of the date of the inspection.
Client #9 was admitted to inpatient treatment on May 5, 2015 and was discharged on May 13, 2015. The facility failed to include documentation of verification that work being done by the client at the project is an integral part of their treatment and rehabilitation plan. Additionally, the facility failed to include documentation of a record of services as of the date of the inspection.
Client #10 was admitted to inpatient treatment on April 13, 2015 and was discharged on May 1, 2015. The facility failed to include documentation of verification that work being done by the client at the project is an integral part of their treatment and rehabilitation plan. Additionally, the facility failed to include documentation of a record of services as of the date of the inspection.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
In review, clients 1,2,3,4,5,6,8,9 and 10 did not have on their treatment plans a listing of 'work therapy'. In addition, records of service were not evident in the client records.
Amended TX plans to include 'work therapy' have been added to the client charts to include the aforementioned identified issue except in the detoxification plan due to no detoxification client will participate in 'work therapy'.
Program Director and Supervisor will ensure during the staff in service to be no later than 6/30/15 to include the need for listing 'work therapy' on all treatment plans. Program Supervisor will develop a template for treatment plans to include work therapy on all 'rehabilitation' treatment plans. In short, no detoxification clients will participate in work therapy.
Program Director and Supervisor will develop a standard ROS (Record of Service) for staff to utilize to ensure compliance. In addition, Program Director and Supervisor will perform randomized chart audits and audit all discharged charts to ensure compliance. |
709.14(b)(4) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(4) Change in activity/discontinuance of an activity.
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Observations
Based on a review of client records and a discussion with the Facility Director and Nursing Supervisor, the facility failed to notify the Department of a change in activity.
The findings include:
On May 20, 2015 through May 21, 2015, ten client records were reviewed for compliance with short-term detoxification and inpatient non-hospital licensure regulations. The facility documented that they were providing Buprenorphine (suboxone) treatment services, an activity for which they do not have Departmental authorization, in four of the ten records reviewed, specifically, client records # 1, 3, 8, and 9.
Client #1 was admitted into detox treatment on May 7, 2015 and was transferred to inpatient treatment on May 12, 2015 and was still an active client at the time of the inspection. Client #1's record included documented medical records and physician/nurse's notes which indicated that client #1 had received Suboxone treatment while in the detoxification level of care.
Client #3 was admitted into detox treatment on May 14, 2015 and was transferred to inpatient treatment on May 19, 2015 and was still an active client at the time of the inspection. Client #3's record included documented medical records and physician/nurse's notes which indicated that client #3 had received Suboxone treatment while in the detoxification level of care.
Client #8 was admitted into detox treatment on March 12, 2015 and was transferred to inpatient treatment on March 17, 2015 and was discharged on March 31, 2015. Client #8's record included documented medical records and physician/nurse's notes which indicated that client #8 had received Suboxone treatment while in the detoxification level of care.
Client #9 was admitted into detox treatment on May 1, 2015 and was transferred to inpatient treatment on May 5, 2015 and was discharged on May 13, 2015. Client #9's record included documented medical records and physician/nurse's notes which indicated that client #9 had received Suboxone treatment while in the detoxification level of care.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
In regards to observation A028, Division Director and Program Director will begin the process of seeking the Buprenorphine waiver as part of the commonwealth mandate for detoxification services. Additionally, the Division Director and Program Director will ask DDAP for technical assistance as it relates to the required information necessary to achieve same. This process will begin immediately at time of submission of this POC. |