INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 9, 2017 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Gaudenzia Focus 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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705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection on June 9, 2017 at approximately 2:00 pm, the facility's bathroom showers on the 3rd floor and in the basement were rusted, had chipped paint, and had mold/mildew growth at the time of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Gaudenzia Maintenance Department will repair, paint and remove all rust, chipped paint, mold/mildew growth from all bathrooms and secure that all facility bathrooms remain in a functional clean and sanitary manner at all times. Focus House staff will also make house runs daily to make certain that the bathrooms remain in good sanitary conditions free of rust, chipped paint, mold/mildew and document in the log book and immediately notify the above maintenance department if any of the above maintenance issues occur so they can be corrected strait away. |
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 the review of client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in 3 of 11 client records. Additionally, 8 of 11 client records had consent to release information forms that were missing the name of the person, agency or organization to whom disclosure was made to.
Client #1 was admitted on 3/21/17 and was still an active client at the time of the inspection. There were consent to release forms signed and dated on 3/21/17 to the primary care physician and an Intensive Case Manager, but they did not include the specific name of a person, agency or organization.
Client #2 was admitted on 11/30/16 and was still an active client at the time of the inspection. There were consent to release forms signed and dated on 12/1/16 to the primary care physician and an Intensive Case Manager, but they did not include the specific name of a person, agency or organization.
Client #3 was admitted on 5/5/17 and was still an active client at the time of the inspection. There were consent to release forms signed and dated on 5/9/17 to the primary care physician and an Intensive Case Manager, but they did not include the specific name of a person, agency or organization.
Client #4 was admitted on 9/12/16 and was discharged on 10/26/16. There was documentation of correspondence with a family member on 9/12/16, 10/4/16 and 11/1/16; however, there was no consent to release information form signed by the client prior to disclosure. Additionally, there were consent to release forms signed and dated on 9/14/16 to the primary care physician and an Intensive Case Manager, but they did not include the specific name of a person, agency or organization.
Client #6 was admitted on 2/11/16 and was discharged on 8/31/16. There was documentation of correspondence with a family member on multiple occasions; however, there was no consent to release information form signed by the client prior to disclosure. Additionally, there were consent to release forms signed and dated on 2/11/16 to the primary care physician and an Intensive Case Manager, but they did not include the specific name of a person, agency or organization.
Client #7 was admitted on 5/8/17 and was still an active client at the time of the inspection. There were consent to release forms signed and dated on 5/9/17 to the primary care physician and an Intensive Case Manager, but they did not include the specific name of a person, agency or organization.
Client #8 was admitted on 9/7/16 and was still an active client at the time of the inspection. There was documentation of correspondence with family members on 5/4/17, 4/1/17, 3//17, 1/7/17, 11/4/16, 10/15/16, and 9/14/16; however, there were no consent to release information forms signed by the client prior to disclosure. Additionally, there were consent to release forms signed and dated on 9/7/16 to the primary care physician and an Intensive Case Manager, but they did not include the specific name of a person, agency or organization.
Client #10 was admitted on 3/27/17 and was discharged on 5/5/17. There was documentation of correspondence with a family member on 3/28/17; however, there was no consent to release information form signed by the client prior to disclosure. Additionally, there was a consent to release form signed and dated on 3/28/17 to the primary care physician and an Intensive Case Manager, but they did not include the specific name of a person, agency or organization.
These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
All client records will be reviewed on a bi-weekly basis by Program Director and the Administrative Assistant to ensure that all client's Confidentiality is maintained and protected. All information will be included in current and future client consent forms, including names of the person, Agency or organization to whom disclosure will be make to. Currently all active clients with incomplete or inappropriate consent in their records have been removed and replaced with new consent forms with the correct disclosure made to the person, agency or organization. |
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
Based on a review of eleven client records, every record lacked documentation verifying written acknowledgement by the clients that each of them had been notified of their client rights, including that facility staff may limit access to their records if determined to be detrimental, the right to appeal a decision limiting access to their records, the reasons for such limitations are to be documented in the record, and the right to request the correction of inaccurate information in the record.
These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
Gaudenzia's Continuous Quality Improvement Director has developed a written policy and procedure on Clients Rights to Access to Records. Program Director will make certain that clients receive these written policy and procedures on Client's Rights and document written acknowledgement by clients that they have been notified of these rights. During the intake process all clients will be notified of their rights to access records and also clients will receive an Orientation Manual upon admission which will inform them of their rights to access records and clients right to rebuke data during the review process. Also there will be a sign off form to acknowledge notification to client. Active Clients will given an In-Service on July 5, 2017 on their Right to inspect their own records. Program Director will make certain that all active members understand the policy and procedure of their rights to access their own records before they sign acknowledgement of notification. |
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
Based on the review of the facility's unusual incident reports on June 9, 2017, it was discovered that the facility failed to notify the Department within 3 days following an unusual incident, which required police presence on-site, that occurred on May 5, 2017.
These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
The facility staff will file a written Unusual Incident Report with the Department of Health Division of Drug and Alcohol Program Licensure within three (3) business days following any Unusual Incident involving the presence of police, fire or ambulance personnel. Also all facility staff will receive an in-service on these procedures. On June 28, 2017 facility formally submitted an Unusual Incident Report to the Department of Health, Division of Drug and Alcohol Program for an on-site police presence which occurred on May 5, 2017. |