INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 13, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Gaudenzia Integrity 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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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
An inspection conducted on February 13, 2019 indicated 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 client record #'s 1, 2, 3, 4, 5, and 7.
Client # 1 was admitted on November 23, 2018 and was still an active client at the time of the inspection. A consent to release form dated November 26, 2018 to a Pharmacy allowed information to be released that included verbiage "coordination of medication" and to a lab dated December 13, 2018 allowing "coordination of lab testing " . The specific information disclosed was not identified.
Client # 2 was admitted on December 21, 2018 and was still an active client at the time of the inspection. A consent to release form dated December 21, 2018 to a Pharmacy allowed information to be released that included verbiage "coordination of medication" and to a lab dated December 21, 2018 allowing "coordination of lab testing " . The specific information disclosed was not identified.
Client # 3 was admitted on January 7, 2019 and was still an active client at the time of the inspection. A consent to release form dated January 7, 2019 to a Pharmacy allowed information to be released that included verbiage "coordination of medication" and to a lab dated January 7, 2019 allowing "coordination of lab testing " . The specific information disclosed was not identified.
Client # 4 was admitted on January 25, 2019 and was still an active client at the time of the inspection. A consent to release form dated February 7, 2019 to an employment agency allowed information to be released that included verbiage "coordination of Employment" and to a lab dated January 25, 2019 allowing "coordination of lab testing " . The specific information disclosed was not identified.
Client # 5 was admitted on August 24, 2018 and was discharged on November 4, 2018. A consent to release form dated August 26, 2018 to a Pharmacy allowed information to be released that included verbiage "coordination of medication". A consent for to an employer dated September 6, 2018 allowed for "progress in treatment" to be released. The specific information disclosed was not identified.
Client # 7 was admitted on September 19, 2018 and was discharged on January 4, 2019. A consent to release form dated September 19, 2018 to a Pharmacy allowed information to be released that included verbiage "coordination of medication " . The specific information disclosed was not identified.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Program Director will review regulation 709.28 with all staff in relation to consents. Staff will document specific information to be released on all client consents and revise any consents that are non-compliant. Program Director will review consents on a monthly basis and report to quality improvement committee to ensure conformance.
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709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
An inspection conducted on February 13, 2019 indicated the facility's client rights policy failed to include documentation of all the required client rights in 7 of 7 client records reviewed that included:
(3) Clients having the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Program Director notified EHR administrators. Administrators of EHR will modify Client Bill of Rights to include: (3) The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record. (4)Clients have the right to appeal a decision limiting access to their records to the director. Program Director will monitor continued conformance via monthly quality chart audits. |
709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
During an on-site licensing inspection conducted on February 13, 2019, the facility failed to document the name of the drug, the dosage, the staff person, the time and the date in client # 2's medical record.
Client # 2 was admitted on December 21, 2018 and was still an active client at the time of the inspection. A review of the medication logged showed that there was no documentation the client received medication by on February 6 and 7, 2019 in the evening and February 8, 2019 in the morning.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Program Director will provide training to all staff on proper documentation on the medication administration record, to include staff signature and client signature for every medication time/dose. Program Director will review the medication log on a monthly basis during quality improvement audits to ensure compliance. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
An inspection conducted on February 13, 2019 and review of 3 discharged clients indicated, the facility failed to notify the client, in writing, of the facility's decision to involuntarily terminate the client in 1 applicable record reviewed.
Client # 5 was admitted on August 24, 2018 and was administratively discharged on November 4, 2018.
The findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
A revised involuntary termination form has been distributed to staff and all staff have been reminded to use the termination form for any involuntary discharge. Program Director will review to ensure these notices are properly completed with clients. Program Director will monitor continued conformance via monthly quality chart audits. |
709.34 (c) (4) 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:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
A review of the unusual incident log conducted on February 13, 2019 indicated there was a reportable incident on February 24, 2018, April 27, 2018, and September 7, 2018 that was not submitted to the Department within the regulatory 3 business day timeframe.
These findings were reviewed with the project and facility staff during the licensing process.
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Plan of Correction
Program Director will provide retraining with all staff on reporting critical incidents to DOH/DDAP within 3 business days and discuss what types of incidents need to be reported. Program Director will oversee the reporting of critical incidents to DOH/DDAP to ensure timely communication and monitor continued conformance during quality improvement audits. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
A review of 7 client records conducted during a licensing inspection on February 13, 2019, indicated a physical examination was not provided in 2 records reviewed.
Client # 1 was admitted on November 23, 2018 and was still an active client at the time of the inspection. A physical examination was not documented in the client record.
Client # 2 was admitted on December 21, 2018 and was still an active client at the time of the inspection. A physical examination was not documented in the client record.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
One physical examination, dated for 12/04/18 and signed by a CRNP, is present for Client #2 which was included in his paperwork from the referring inpatient facility. Program Director will remind intake staff that clients must have a documented physical examination as part of the intake procedure. Program Director will monitor continued conformance via monthly quality chart audits. |
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
An inspection conducted on February 13, 2019 indicated the facility failed to provide documentation of a complete client record in 7 of 7 records reviewed.
Client # 1 was admitted on November 23, 2018 and was still an active client at the time of the inspection. The facility failed to document verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
Client # 2 was admitted on December 21, 2018 and was still an active client at the time of the inspection. The facility failed to document verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
Client # 3 was admitted on January 7, 2019 and was still an active client at the time of the inspection. The facility failed to document verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
Client # 4 was admitted on January 25, 2019 and was still an active client at the time of the inspection. The facility failed to document verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
Client # 5 was admitted on August 24, 2018 and was discharged on November 4, 2018. The facility failed to document verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan, a case consultation prior to discharge, and a follow-up after discharge.
Client # 6 was admitted on November 1, 2018 and was discharged on November 27, 2018. The facility failed to document verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan, a case consultation prior to discharge, and a follow-up after discharge.
Client # 7 was admitted on September 19, 2018 and was discharged on January 4, 2019. The facility failed to document verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan, a case consultation prior to discharge, and a follow-up after discharge.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
All clinical staff will add work therapy on the client's individual treatment plans and Program Director will monitor charts for compliance on a monthly basis during the quality improvement monitoring process. |