INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on October 22, 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 DRC, 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
|
705.10 (c) (1) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(1) Maintain a portable fire extinguisher with a minimum of an ABC rating, which shall be located on each floor. If there is more than 2,000 square feet of floor space on a floor, the residential facility shall maintain an additional fire extinguisher for each 2,000 square feet or fraction thereof.
|
Observations
The facility failed to maintain a portable fire extinguisher with a minimum of an ABC rating located on each floor.The fire extinguisher on the 7th floor had been removed and facility staff was unable to locate its whereabouts.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Gaudenzia DRC Inpatient will maintain a portable fire extinguisher with a minimum of an ABC rating, which will be located on each floor. This will be reviewed with the Clinical Supervisor in a documented supervision session no later than 12/6/24. A portable fire extinguisher with a minimum of an ABC rating was obtained on 10/23/24 and placed on the floor.
The Program Director will ensure that a fire extinguisher with a minimum of an ABC rating is always located on each floor without exception. The Program Director will monitor each floor daily to ensure that there is a fire extinguisher on the floor.
If any issues are noted, the Program Director will immediately contact the maintenance department to obtain a new fire extinguisher.
|
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
|
Observations
Based on the review of fire drill logs from October 2023 through September 2024, the facility failed to conduct a fire drill during sleeping hours at least every 6 months.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Gaudenzia DRC Inpatient will conduct an unannounced fire drill during sleeping hours at least every 6 months. This will be reviewed with the Clinical Supervisor in a documented supervision session no later than 12/6/24.
The Program Director will ensure that unannounced fire drills are conducted during sleeping hours at least every 6 months. The Program Director will review monthly fire drill logs and reports to confirm there are at least 1 unannounced fire drill during sleeping hours within a 6-month period.
If any issues are noted, the Program Director will ensure that additional drills are completed during sleeping hours.
|
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.
|
Observations
Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one of seven client records reviewed. Client #3 was admitted on August 28, 2024, and was a current client at the time of the licensing inspection. A release of information form for the funding source was not documented in the client record; however, the facility verified that billing had occurred.These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Gaudenzia DRC Inpatient will obtain an informed and voluntary consent for all relevant funding sources from each client for the disclosure of information and documented in the chart record upon admission at billing verification. This will be reviewed with all staff in a documented staff meeting no later than 12/6/24.
A release will be completed for Client #3 no later than 11/29/24.
The Clinical Supervisor will review each new admission chart to confirm that all required consents are documented in the chart upon admission. Additionally, The Program Director will audit each newly admitted client chart to confirm that all required consents are documented in the chart upon admission.
Any issues noted will be reviewed with the clinician in a documented supervision session and corrected within 48 hours.
|
709.28 (c) (4) 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 must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
|
Observations
Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included a dated client signature in one of seven client records reviewed. Client #6 was admitted on June 28, 2024, and was discharged on August 5, 2024. A release of information for the funding source was documented in the record and signed by a witness on June 28, 2024; however, the form was not signed and dated by the client. These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Gaudenzia DRC Inpatient will obtain an informed and voluntary consent for all relevant funding sources, ensure releases of information have the dated client signature prior to disclosing any information and documented in the chart record upon admission at billing verification and prior to the disclosure of information. Obtaining a signed informed and voluntary consent for all relevant funding sources prior to the disclosure of information will be reviewed with all staff in a documented staff meeting no later than 1/10/2025.
The counselor will obtain releases of information that are dated with the client signature prior to disclosing any information upon admission and ongoing as needed. The Clinical Supervisor will review each new admission chart and perform random chart audits bi-weekly to confirm that all required consents are signed and dated by the client and documented in the chart upon admission and ongoing as needed. Additionally, The Program Director will audit each newly admitted client chart and random chart audits monthly to confirm that all required consents are signed and dated by the client and documented in the chart upon admission and ongoing as needed.
Any issues noted will be reviewed with the clinician in a documented supervision session and corrected within 48 hours.
|
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
|
Observations
Based on a review of client records, the project failed to ensure that counseling services are provided according to the individual treatment and rehabilitation plan in five of seven client records reviewed.Client #1 was admitted on September 4, 2024 and was a current client at the time of the inspection. A comprehensive treatment plan was documented in the record on September 6, 2024, indicated that the client was to receive one individual counseling session per week; however, there were no individual counseling sessions documented in the record for the weeks of September 8, 2024 through September 14, 2024, September 15, 2024 through September 21, 2024, September 22, 2024 through September 28, 2024, September 29, 2024 through October 5, 2024, October 6, 2024 through October 12, 2024 and October 13, 2024 through October 19, 2024.Client #2 was admitted on September 27, 2024 and was a current client at the time of the inspection. An initial treatment plan was documented in the record on September 30, 2024, indicated that the client was to receive one individual counseling session per week; however, there was no individual counseling session documented in the record for the week of October 6, 2024 through October 12, 2024.Client #3 was admitted on August 28, 2024 and was a current client at the time of the inspection. An initial treatment plan was documented in the record on September 2, 2024, indicated that the client was to receive one individual counseling session per week; however, there were no individual counseling sessions documented in the record.Client #6 was admitted on June 28, 2024 and was discharged on August 5, 2024. A comprehensive treatment plan was documented in the record on July 2, 2024, indicated that the client was to receive one individual counseling session per week; however, there were no individual counseling sessions documented in the record for the weeks of July 7, 2024 through July 13, 2024, July 14, 2024 through July 20, 2024, July 21, 2024 through July 27, 2024 and July 28, 2024 through August 3, 2024.Client #7 was admitted on June 27, 2024 and was discharged on August 26, 2024. A initial treatment plan was documented in the record on June 28, 2024, indicated that the client was to receive one individual counseling session per week; however, there were no individual counseling sessions documented in the record for the weeks of July 7, 2024 through July 13, 2024, July 14, 2024 through July 20, 2024, July 21, 2024 through July 27, 2024, July 28, 2024 through August 3, 2024, August 4, 2024 through August 10, 2024, August 11, 2024 through August 17, 2024, and August 18, 2024 through August 24, 2024.These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Gaudenzia DRC Inpatient will ensure that counseling services are provided according to the individual treatment and rehabilitation plan. Counselors will develop and post a document schedule where all new clients are added to the schedule upon admission. Counselors will meet with each client for a 1:1 counseling session, as detailed in the treatment plan, weekly and will document the session in the clients' chart. This will be reviewed with all staff in a documented staff meeting no later than 12/6/24.
The Clinical Supervisor will review and confirm daily that each Counselor completes the required weekly counseling session(s) according to the treatment plan and their submitted document schedule. The Program Director will review charts weekly to confirm required weekly counseling session(s) are completed and documented in client chart record as per regulations.
Any issues noted will be reviewed with the clinician in a documented supervision session and corrected within 48 hours.
|
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
|
Observations
Based on the review of client records, the project failed to document a complete client record on an individual that included follow-up contact notes in three of four applicable client records reviewed.Client #4 was admitted on March 27, 2024 and was discharged on April 19, 2024. There was no follow-up contact documented in the client record.Client #5 was admitted on April 24, 2024 and was discharged on May 31, 2024. There was no follow-up contact documented in the client record.Client #6 was admitted on June 27, 2024 and was discharged on August 5, 2024. There was no follow-up contact documented in the client record.These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Gaudenzia DRC Inpatient Intake Specialist will complete follow-up contact notes for each discharged client within 30 days of discharge. This will be reviewed with the Intake Specialist in a documented supervision session no later than 11/29/24.
The Clinical Supervisor will audit all discharged notes to confirm completed follow-up contact notes on each discharged client is noted in the chart within 30 days of discharge and notify Program Director of completed discharged chart. The Program Director will audit all completed charts to ensure completed follow-up contact notes on each discharged client are completed within the 30-day window.
Any issues noted will be reviewed with the Intake Specialist in a documented supervision session and corrected within 48 hours.
|