INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 7, 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. Re-Entry House 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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705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on a physical plant inspection on June 7, 2022, the facility failed to ensure that garbage was stored in covered containers that prevent the penetration of insects and rodents as two trash receptacles outside in the courtyard of the building were uncovered.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On July 6, 2022, Program received new trash receptacles with attached covers for outside in the courtyard and replaced the uncovered trash receptacles identified above. Program Director will review the licensing standard and expectations with all staff during next General Staff Meeting (July 14, 2022) to ensure awareness of expected practice and compliance.
Program Director and/or designee will monitor the outside trash receptacles on a monthly basis during completion of monthly safety report/inspection to ensure all trash receptacles maintain properly functioning covers to prevent penetration of insects and/or rodents.
This will also be monitored on a quarterly basis by the Quality Assurance department during regular program audits using the physical plant audit tool. Any issues identified will be brought to the immediate attention of the Program Director.
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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 seven 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 #4 was admitted on January 10, 2022 and discharged Against Medical Advise (AMA) on April 3, 2022. The facility failed to follow their policy related to AMA discharges of calling the Emergency Contact within twelve hours.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
An In-Service Training will be held to educate and/or review the Agency's policy regarding notification of Emergency Contact and documentation expectations for individuals that leave treatment Against Staff Advise. . This In-Service Training will be held with the Clinical Staff of Re-Entry on July 14, 2022. Program Director will highlight the expectations of the notification of an Emergency Contact within twelve hours for any individual that leaves the program Against Staff Advise.
On a daily basis, Program Director will consult 3rd Shift Operational Staff to receive any notification about any individuals that have failed to return to the program. In the event that an individual has left the program Against Staff Advise, Program Director will communicate the need for the Emergency contact to be notified and documented. In the event of counselor absence (weekend, holidays, vacation, and/or other absences), Program Director will be responsible to notify and document notification of Emergency Contact within the established/required twelve hour timeframe.
Program Director will be responsible for ensuring that this workflow expectation/addition is followed during monthly audits of all discharged charts.
This compliance with licensing standard will also be monitored on a quarterly basis by Executive Director and/or Deputy Regional Director (or designee) when Program Director submits quarterly report on plan of corrections and status of compliance. This will also be monitored by the Regional Quality Assurance Manager during quarterly audits of program charts.
All such audits will be documented using the Gaudenzia Quantitative audit tool.
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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 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, led by the Chief Financial Officer, 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 to ensure that all understand the importance of timely completion of the Financial Audit.
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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 a review of seven records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in one record reviewed. Additionally, the facility failed to keep disclosures of client identifying information with the limits established by Pa Code 255.5 (b) in two records reviewed.
Client #3 was admitted on March 15, 2022 and was discharged on March 29, 2022. The record did not contain a client signed consent to release information form to the funding source and there was evidence of billing.
Client #4 was admitted on January 10, 2022 and was discharged on April 3, 2022. The consent to release information forms to the funding source signed by the client on January 10, 2022, allowed for the release of psychological and psychiatric evaluations, which exceeds the limits established in Pa Code 255.5(b).
Client #5 was admitted on February 22, 2022 and was active at the time of the inspection. The consent to release information forms to the funding source signed by the client on February 22, 2022, allowed for the release of psychological and psychiatric evaluations, which exceeds the limits established in Pa Code 255.5(b).
This is a repeat citation from the October 2, 2020 and June 9, 2021 annual licensing inspections.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To address the consent form for the Client #5 (active at the time of the inspection), Program Director placed a note in member's chart pinpointing the identified deficiency and redid the consent form to only release information in accordance with the guidelines/limits established in Pa Code 255.5. This correction was completed on June 17, 2022.
Program Director will develop a form to systematically review all consent forms completed for new admissions to be completed by the Administrative Assistant on a biweekly basis. This will be added to the pre-existing plan of corrections, which failed to fully address this repeated deficiency.
Program Director and Administrative Assistant will review these forms/reports on a monthly basis to ensure completion and compliance. This initial review will take place on July 15, 2022.
In addition to this, Program Director will be responsible for ensuring that this workflow expectation/addition is followed during monthly audits of all individuals admitted to the program.
This compliance with licensing standard will also be monitored on a quarterly basis by Executive Director and/or Deputy Regional Director (or designee) when Program Director submits quarterly report on plan of corrections and status of compliance. This will also be monitored by the Regional Quality Assurance Manager during quarterly audits of program charts.
All such audits will be documented using the Gaudenzia Quantitative audit tool.
During monthly supervisory sessions, any missing notifications will be brought to the attention of the appropriate party, either clinician and/or administrative assistant. Any identified deficiencies will be immediately rectified. |
709.32 (c) (1) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication, including the documentation of the administration of medication:
(i) By individuals permitted to administer by Pennsylvania law.
(ii) When self administered by the client.
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Observations
Based on a review of seven client records, the facility failed to follow their written policy of documenting medication administration in three records reviewed.
Client #1 was admitted on November 8, 2021 and discharged on January 8, 2022. The record contained documentation of medication administered on the following dates that did not include the time of medication administration:
December 13, 2021
December 12, 2021
December 11, 2021
December 3, 2021
December 2, 2021
November 25, 2021
Client #2 was admitted on November 17, 2021 and discharged on March 14, 2022. The record contained documentation of medication administered on the following dates that did not include the time of medication administration:
January 2, 2022
January 3, 2022
January 4, 2022
January 6, 2022
January 7, 2022
January 9, 2022
January 10, 2022
January 14, 2022
Client #4 was admitted on January 10, , 2022 and discharged on April 3, 2022. The record contained documentation of medication administered on the following dates that did not include the time of medication administration:
January 15, 2022
January 17, 2022
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An In-Service Training will be conducted with the Operational Staff of Re-Entry House on July 14, 2022 to review the agency's policy regarding documentation expectations of medication monitoring and recording, which are to include the time that the medication was self-administered/monitored.
Program Director will be responsible for ensuring that this workflow expectation/addition is followed during monthly audits of charts, to include the MAR.
This compliance with licensing standard will also be monitored on a quarterly basis by Executive Director and/or Deputy Regional Director (or designee) when Program Director submits quarterly report on plan of corrections and status of compliance. This will also be monitored by the Regional Quality Assurance Manager during quarterly physical plant tours.
During monthly supervisory sessions, any incomplete MAR's will be brought to the attention of the appropriate party and immediately rectified.
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709.54(c) LICENSURE Follow-up policy
709.54. Project management services.
(c) The project shall develop a written client follow-up policy.
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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.
Client #1 was admitted on November 8, 2021 and discharged on January 8, 2022. The facility failed to document the results of a follow up attempt in the record.
Client #3 was admitted on March 15, 2022 and was discharged on March 29, 2022. The facility failed to follow up with the referral treatment provider within seven days of the client ' s discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An In-Service Training will be conducted with the Clinical Staff of Re-Entry House on July 14, 2022 to review the agency's policy and documentation expectations of follow-up attempts. This In-Service Training will include contacting the treatment provider to which the individual was referred, as well as proper completion of the form to ensure that the results of the follow-up attempt are captured.
Program Director will be responsible for ensuring that this workflow expectation/addition is followed during monthly audits of all discharged charts.
This compliance with licensing standard will also be monitored on a quarterly basis by Executive Director and/or Deputy Regional Director (or designee) when Program Director submits quarterly report on plan of corrections and status of compliance. This will also be monitored by the Regional Quality Assurance Manager during quarterly audits of program charts.
All such audits will be documented using the Gaudenzia Quantitative audit tool.
During monthly supervisory sessions, any missing notifications will be brought to the attention of the appropriate party. Any identified deficiencies will be immediately rectified.
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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 obtaining client signed consent to release information forms and keeping disclosures of information within the limits established by 4 Pa. Code 255.5 was submitted and approved by the Department for the October 2, 2020 and June 9, 2021 annual licensing inspections. Obtaining client signed consent to release information forms prior to disclosing information and keeping disclosures within the limits of 4 Pa. Code 255.5 was again found to be a deficiency in the June 7, 2022 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will have ultimate responsibility for ensuring that this plan of correction is fully implemented and adhered to on an ongoing basis at the program. While the previously approved plans of corrections failed to fully address these deficiencies, a revision to the formally approved plans of corrections was needed.
Effective immediately, in addition to the on-site monitoring by the Program Director as described in the deficiency Observation 0275, Executive Leadership and/or Deputy Regional Director will provide ongoing and directed oversight of each plan of correction item and will conduct documented reviews of the plan of correction on a quarterly basis and provide direct feedback to the Program Director to be documented in supervision notes.
In addition to the local and regional monitoring described above, the Regional Quality Improvement Manager and/or Quality Assurance Department will conduct at least quarterly reviews of the program to include qualitative and quantitative chart audits, and a specific review of each plan of correction item. Any issues identified during these reviews will be immediately brought to the attention of the Program Director to be corrected immediately, as well as being noted on the Quantitative and Qualitative audit tools, and on the summary sheet which includes a Performance Improvement Plan to be developed in conjunction with the Program Director and Executive Leadership and/or Deputy Regional Director.
Any missing documentation or documentation requiring correction will be completed by the appropriate party within 48 hours.
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