INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 18 & 19, 2010 by staff from the Division of Drug and Alcohol 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 and a plan of correction is due on November 30, 2010.
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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 conducted on October 19 & 20, 2010 and an interview with the Facility Director, the facility failed to provide covered containers for garbage/rubbish to prevent the penetration of insects and rodents.
The findings include:
On October 19, 2010 at approximately 10:30 AM and on October 20, 2010 at 1:30 PM - 3:00 PM a physical plant inspection was conducted. On both days, it was observed that the facility's dumpster lacked lids, one lid was missing and one was broken and half of the lid missing. The Facility Director confirmed that the covers were missing.
This deficiency was corrected prior to the licensing staff leaving the facility.
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Plan of Correction
A training to review the storage of trash, garbage, and rubbish in covered containers will be facilitated on December 15, 2010. The training will ensure that all maintenance staff dispose of trash in the covered trash containers as required by the Division of Drug and Alcohol Licensure DOH Policy 705.22(4).
All storage of trash, garbage, and rubbish will be reviewed weekly and monitored during monthly Continuous Quality Improvement (CQI) meetings to ensure compliance, completion, and timelines by the Operations Director.
Persons Responsible: Division Director, Operations Director, Inpatient Program Director.
Timeframe for Completion: January 20, 2011
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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 upon a review of client records and a discussion with the Facility Director on October 20, 2010, the facility failed to comply with 4 Pa. Code 255.5 relating to projects and coordinating bodies: disclosure of client-oriented information.
The findings include:
On October 20, 2010, 9 client records were reviewed for consents to release information and client related correspondences. Nine out of nine records reviewed, #1-9 inclusive, contained consent to release information forms that permitted the facility to act in reliance on a client's verbal consent to release information. This is in violation of 709.28 (c)
(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:
(1)Name of the person, agency or organization to whom disclosure is made.
(2)Specific information disclosed.
(3)Purpose of disclosure.
(4)Dated signature of client or guardian.
(5)Dated signature of witness.
(6) Expiration date of the consent.
Client # 1 was admitted on 7/8/10 and discharged on 9/8/10. Consents to release information to government agencies and third party funding sources, all allowed the facility to act in reliance on a client's verbal consent to release information.
In addition, client record # 1 contained parts of biopsychosocial histories for two other clients and a group note for a third client intermixed within the biopsychosocial histories of client #1.
Client # 2 was admitted on 7/23/10 and discharged on 9/17/10. Consents to release information to government agencies and third party funding sources, all allowed the facility to act in reliance on a client's verbal consent to release information.
Client # 3 was admitted on 7/21/10 and discharged on 9/14/10. Consents to release information to government agencies and third party funding sources, all allowed the facility to act in reliance on a client's verbal consent to release information.
Client # 4 was admitted on 8/29/10. Consents to release information to government agencies and third party funding sources, all allowed the facility to act in reliance on a client's verbal consent to release information.
Client # 5 was admitted on 9/16/10. Consents to release information to government agencies and third party funding sources, all allowed the facility to act in reliance on a client's verbal consent to release information.
Client # 6 was admitted on 9/3/10. Consents to release information to government agencies and third party funding sources, all allowed the facility to act in reliance on a client's verbal consent to release information.
Client # 7 was admitted on 8/23/10. Consents to release information to government agencies and third party funding sources, all allowed the facility to act in reliance on a client's verbal consent to release information.
Client # 8 was admitted on 9/6/10. Consents to release information to government agencies and third party funding sources, all allowed the facility to act in reliance on a client's verbal consent to release information.
Client # 9 was admitted on 8/9/10 and discharged on 9/8/10. Consents to release information to government agencies and third party funding sources, all allowed the facility to act in reliance on a client's verbal consent to release information.
The Facility Director confirmed that the consent to release information forms in client records # 1 - 9 contained verbiage allowing the facility to act in reliance on the client's verbal consent to release information.
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Plan of Correction
The word "verbal" has been taken out of the Confidentiality Request to Release Information Form and the agency Policy and Procedure Manual.
A record-keeping training to include a review of the revised Confidentiality Request to Release Information Form and Policy and Procedure standards will be facilitated on December 10, 2010 to ensure that all staff release client information per DOH Policy 709.28(a)(1) and 4 Pa. Code 255.5.
All existing inaccurate filed information will be removed and re-filed as appropriate. In addition, existing consent to release information forms will be voided and new consent to release information forms will be completed where appropriate.
All consent to release information documentation and compliance timeframes will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings and to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible: Division Director, Inpatient Program Director.
Timeframe for Completion: January 20, 2011
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709.30(1) LICENSURE Client Rights
709.30. Client rights.
(1) A person 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
Based on a review of the resident handbook and an interview with the Facility Director, the facility failed to ensure that a person 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.
The findings include:
On October 18, 2010 the facility's policies and procedures and the resident handbook were reviewed. Page 12 of the resident handbook contained the following statement: "When mail is delivered ... if packages or letters appear suspicious in nature... or addressed from an inappropriate person, the Director of Operations shall inspect and if necessary open the letter or package."
The Facility Director confirmed that this was the facility's policy.
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Plan of Correction
To ensure that resident mail is handled appropriately, Inpatient Director and the Clinical Supervisor will review and correct the resident handbook. All mail will be given to the resident and he/she will open the mail in the presence of the counselor, Clinical Supervisor, or the Inpatient Director.
Staff will be trained on revision of Inpatient resident handbook on December 10, 2010. Inpatient resident handbook will be reviewed with clients during Orientation Sessions.
Distribution of mail will be monitored by the Inpatient Director and the Clinical Supervisor.
Persons Responsible:
Inpatient Director
Clinical Supervisor
Division Director
Timeframe for Completion: January 20, 2011.
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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
Based upon a review of client records and an interview with the Facility Director, the facility failed to complete a physical examination within seven days as per facility policy for clients in three of nine records reviewed.
The findings include:
The facility policy states that physical examinations are to be scheduled within 24 hours of admission and are to be completed within seven days.
Nine client records were reviewed on October 19, 2010 for physical examinations. The facility failed to document a physical examination within seven days in three out of nine client records reviewed, specifically, # 6, 7 & 9.
Client # 6 was admitted on 9/3/10. The physical examination was not completed until 9/15/10.
Client # 7 was admitted on 8/23/10. The physical examination was not completed until 9/2/10.
Client # 9 was admitted on 8/9/10. There was no documentation of a physical examination in client record # 9 as of 10/19/10.
The Facility Director confirmed that physical examinations had not been completed within seven days as per facility policy in client records # 6, 7 & 9.
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Plan of Correction
To ensure that a resident's physical examination is completed within seven (7) days, a column will be added to the Inpatient Daily Roster to document when the physical examination is due and when it has been completed. This revision of the daily roster will be completed by December 1, 2010.
The Inpatient Director and the Clinical Supervisor will keep a running log of all new admissions who need physical examinations. Once the physical examination has been completed, the Clinical Supervisor will receive a copy of the physical for the client record.
All physicals will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible:
Clinical Supervisor
Program Director
Medical Administrator
Timeframe for Completion: January 20, 2011.
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709.53(a)(3) LICENSURE Records of Service
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:
(3) Record of services provided.
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Observations
Based upon a review of client records and an interview with the Facility Director, the facility failed to document a record of service to include all services provided in seven out of nine records reviewed.
The findings include:
Nine client records were reviewed for the record of services on October 19, 2010. Seven out of nine records reviewed lacked documentation to show all services provided, specifically, # 1, 2, 3, 4, 5, 6, & 9.
Client # 1 was admitted on 7/8/10 and discharged on 9/8/10. The record of services failed to list the dates of individual counseling sessions, who provided them and how long the sessions lasted.
Client # 2 was admitted on 7/23/10 and discharged on 9/17/10. The record of services failed to list the dates of individual counseling sessions, who provided them and how long the sessions lasted.
Client # 3 was admitted on 7/21/10 and discharged on 9/14/10. The record of services failed to list the dates of individual counseling sessions, who provided them and how long the sessions lasted.
Client # 4 was admitted on 8/29/10. The record of services failed to list the dates of individual counseling sessions, who provided them and how long the sessions lasted.
Client # 5 was admitted on 9/16/10. There was no record of services in the client record as of 10/19/10.
Client # 6 was admitted on 9/3/10. The record of services failed to list the dates of individual counseling sessions, who provided them and how long the sessions lasted.
Client # 9 was admitted on 8/9/10. There was no record of services in the client record as of 10/19/10.
The Facility Director confirmed that a record of services was missing in client records # 5 & 9, and that the records of services in client records # 1, 2, 3, 4, & 6 failed to include documentation of all of the individual sessions, who provided the services and how long the sessions were.
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Plan of Correction
To ensure that a record of service and all services provided are completed in every client record, Inpatient Director and Clinical Supervisor will conduct a training with the clinical staff on DOH Policy 709.53(a)(3) on November 19, 2010. The training will review the different components of the record of service which include: the dates of the service, who provided the service and the duration of the service.
All documentation of record of services will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings to ensure compliance, completion, and timeframes by the Program Director.
Persons Responsible:
Inpatient Director
Clinical Supervisor
Timeframe for Completion: January 20, 2011.
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709.53(a)(5) LICENSURE Progress Notes
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:
(5) Progress notes.
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Observations
Based upon a review of client records and an interview with the facility director, the facility failed to develop a plan appropriate for the group and/or individual following the static group sessions in two of nine records reviewed.
The findings include:
Nine client records were reviewed on 10/19/10 for progress notes. The facility failed to develop a plan appropriate for the group and/or individual following the static group sessions in two of nine records reviewed.
The plan listed in the progress notes for the static group sessions were preprinted plans that were the same in each static group progress notes in two of nine records reviewed, specifically, client records # 1 & 2.
The Facility Director confirmed that the progress notes for the static group sessions in client records # 1 & 2 were preprinted and were not developed specifically for the session.
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Plan of Correction
To ensure that an individualized plan is developed for group and/or individual sessions, a training with the clinical staff on DOH Policy 709.53(a)(5) will be conducted on November 19, 2010 by the Inpatient Director and the Clinical Supervisor.
Progress note documentation will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings to ensure compliance, completion, and timeframes by the Program Director.
Persons Responsible:
Inpatient Director
Clinical Supervisor
Timeframes for Completion: January 20, 2011.
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