INITIAL COMMENTS
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This report is a result of an off-site licensure renewal inspection conducted on January 20, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the off-site inspection, Gaudenzia, DRC, Inc. was found not 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) (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 must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of seven client records on January 20, 2021, the facility failed to provide a consent to release form that included specific information to be disclosed.
Client # 3 was admitted on November 25, 2020 and was still an active client at the time of the inspection. Consent forms dated November 25, 2020 to three different labs, two different funding sources, the Department of Corrections and Probation and Parole did not state what information was to be released.
Client # 4 was admitted on December 7, 2020 and was still an active client at the time of the inspection. Consent forms dated December 8, 2020 to three different labs, the funding source, the emergency contact, the Department of Corrections and Probation and Parole did not state what information was to be released.
Client # 5 was admitted on November 12, 2020 and was discharged on January 11, 2021. Consent forms dated November 12, 2020 to three different labs, two different funding sources, the emergency contact, the Department of Corrections and Probation and Parole did not state what information was to be released.
Client # 6 was admitted on September 24, 2020 and was discharged on November 27, 2020. Consent forms dated September 24, 2020 to three different labs, three different funding sources, the emergency contact, the Department of Corrections and Probation and Parole did not state what information was to be released.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
All consent to release information forms will identify specific information to be disclosed.
The Clinical Director will review consent to release information forms to see that the boxes have been checked off appropriate and has the required signatures.
There will an in-service staff training, held by the Clinical Director on completing consent to release information forms at the Inpatient Staff Meeting on Tuesday, February 16, 2021.
The In-service training will explain Specific information to be disclosed: 1. Voluntary consent from the client for the release of information contained in the client record will be in writing and include, specific information to be 1. Voluntary consent from the client for the release of information contained in the client record will be in writing and include, specific information to be released.
2. Information pertaining to whether the client is or is not in treatment
3. Client's prognosis
4. The nature of the project
5. A brief description of the client's progress
6. A short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse
7. Other as deemed necessary This information will be released to labs, funding sources, emergency contact, the Department of Corrections and Probation and Parole will be checked off on the Consent to Release form and signed by the client and staff.
Person Responsible: Clinical Director
Targeted Completion Date: February 16, 2021
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709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of seven client records on January 20, 2021, the facility failed to provide a consent to release form that included the purpose of disclosure.
Client # 3 was admitted on November 25, 2020 and was still an active client at the time of the inspection. Consent forms dated November 25, 2020 to three different labs, two different funding sources, the Department of Corrections and Probation and Parole did not state the purpose of disclosure.
Client # 4 was admitted on December 7, 2020 and was still an active client at the time of the inspection. Consent forms dated December 8, 2020 to three different labs, the funding source, the emergency contact, the Department of Corrections and Probation and Parole did not state the purpose of disclosure.
Client # 5 was admitted on November 12, 2020 and was discharged on January 11, 2021. Consent forms dated November 12, 2020 to three different labs, two different funding sources, the emergency contact, the Department of Corrections and Probation and Parole did not state the purpose of disclosure.
Client # 6 was admitted on September 24, 2020 and was discharged on November 27, 2020. Consent forms dated September 24, 2020 to three different labs, three different funding sources, the emergency contact, the Department of Corrections and Probation and Parole did not state the purpose of disclosure.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
All consent to release information forms will identify purpose of disclosed.
The Clinical Director will review consent to release information forms to see that the purpose of disclosure is indicated.
There will an in-service staff training, held by and Clinical Director on completing consent to release information forms during Inpatient Staff Meeting on Tuesday, February 16, 2021.
Gaudenzia DRC, Inc Inpatient shall obtain an informed and voluntary consent from the client for the release of information contained in the client record. The consent will be in writing and include the purpose of disclosure. The disclosure is required for the following purposes:
1. To provide funding for ongoing treatment efforts.
2. To obtain insurance or employment of government benefits.
3. To enable judges, attorneys, probation and parole officers to support treatment goals or to make legal decisions on behalf of the client.
4. To coordinate treatment efforts with family, concerned persons and case manager.
5. To coordinate treatment efforts with my employer.
Person Responsible: Clinical Director
Targeted Completion Date: February 16, 2021
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709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of seven client records, the facility failed to review and update treatment and rehabilitation plans every thirty days.
Client # 1 was admitted on November 5, 2020 and was current at the time of the inspection. Client #1 had treatment plans on November 5, 2020, November 27, 2020 and December 3, 2020. Client #1 should have had another treatment plan no later than January 3, 2021 however did not have another Treatment plan update documented until January 14, 2021.
Client # 3 was admitted on November 25, 2020 and was current at the time of the inspection. Client #3 had treatment plans on November 25, 2020 and December 3, 2020. Client #3 should have had another treatment plan no later than January 3, 2021; however did not have another Treatment plan update documented until January 12, 2021.
Client # 6 was admitted on September 24, 2020 and was discharged on November 27, 2020. Client #6 had a treatment plan on September 24, 2020. Client #6 should have had treatment plans no later than October 24, 2020 and November 24, 2020; however did not have any other Treatment plans documented in the record.
Client # 7 was admitted on October 30, 2020 and was discharged on January 13, 2021. Client #7 had treatment plans on October 30, 2020 and November 18, 2020. Client #7 should have had a treatment plan no later than December 18, 2020, but did not have one documented in the record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will review all treatment plans during supervision bi-weekly. This will become part of the quality improvement process and documented. In addition, a random audit of charts will be conducted for accuracy and signed within the timeframe of thirty days.
Person Responsible: Clinical Director
Targeted Completion Date: February 16, 2021
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