INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 19-21, 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, Inc. People With Hope/Short-Term Program 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
Based on a review of 11 client records, 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 1 record. Additionally, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in 8 records. Also, there were consent to release information forms missing some of the required information in 3 records.
Client # 2 was admitted on 5/5/17 and was still an active client at the time of the inspection. There was documentation that the facility had billed the funding source; however, there was no consent to release information form on file prior to the disclosure.
Client # 3 was admitted on 4/11/17 and was an active client at the time of the inspection. A consent to release information form was signed and dated on 5/11/17 to an outside agency, however, the form did not include the purpose of disclosure or the specific information to be disclosed. Additionally, there was documentation that the facility had billed the funding source; however, there was no consent to release information form on file prior to the disclosure.
Client # 4 was admitted on 8/2/16 and was discharged on 8/14/16. A consent to release information form was signed and dated on 8/2/16 to the funding source with an expiration date of 8/2/16. No updated consent to release form was documented at the time of inspection and there was documentation that the facility had billed the funding source.
Client # 5 was admitted on 1/26/17 and was discharged on 5/2/17. The record contained documentation of a facsimile, dated 4/20/17, containing UDS results to a probation/parole office, which exceeded the limits established by 4 Pa. Code 255.5. Additionally, there was documentation that the facility had billed the funding source; however, there was no consent to release information form on file prior to the disclosure.
Client # 6 was admitted on 2/24/17 and was discharged on 4/5/17. There was documentation that the facility had billed the funding source; however, there was no consent to release information form on file prior to the disclosure.
Client # 7 was admitted on 6/6/17 and was still an active client at the time of the inspection. A consent to release information form was signed and dated 6/6/17, however, the form did not include the specific name of the person, agency or organization, the specific information to be disclosed, the purpose for the disclosure or the expiration date. Additionally, there was documentation that the facility had billed the funding source; however, there was no consent to release information form on file prior to the disclosure.
Client # 9 was admitted on 5/31/17 and was an active client at the time of the inspection. A consent to release form was signed and dated on 6/19/17 to the probation officer, however, the form did not include the specific name of the person, agency or organization
Client # 10 was admitted on 9/26/16 and was discharged on 2/22/17. The record contained documentation of a facsimile to an outside agency on 2/23/17, another facsimile was sent on 2/21/17 to a different agency disclosing the birth certificate, insurance, medical history, and medications, and a third facsimile was sent to a different agency on 2/27/17 disclosing the discharge summary, however, there were no consent to release information forms on file to any of the three outside agencies prior to the disclosure.
Client # 11 was admitted on 2/22/17 and was discharged on 3/16/17. There was documentation that the facility had billed the funding source; however, there was no consent to release information form on file prior to the disclosure.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
A consent form for the funding source was completed on Client #2, #3, #4 and #7.
The missing elements of the consent form were addressed in Client records #3, #7, and #9.
A record-keeping training to include a review of confidentiality standards will be facilitated on July 25, 2017 to ensure that all staff adhere to confidentiality standards per DOH Policy 709.28 (c).
All Release of Information Forms will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) for three (3) months to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible: Compliance Director, Division Director, Program Director.
Timeframe for Completion: July 25, 2017
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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
Based on a review of 11 client records, the record for client #9, admitted on 5/31/17 and was still an active client, lacked documentation verifying written acknowledgement by the client that they had been notified of some 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
We revised the intake package to ensure that all Client Rights Forms are congruent.
Client #9 completed the revised Client Rights Form on 7/19/17.
A record-keeping training to include a review of client rights standards will be facilitated on July 25, 2017 to ensure that all staff adhere to Client Rights Policy per DOH Standard 709.30 (1)
Client Charts will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) for three (3) months to ensure program compliance of Standard 709.30 (1).
Persons Responsible: Compliance Director, Division Director, Program Director.
Timeframe for Completion: July 25, 2017
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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 20, 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 April 29, 2017.
These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
On 7/19/17 DDAP was sent the Unusual Incident Report for the 4/29/17 incident in which police arrived to the facility.
An In Service Training was conducted on 7/18/2017 with directors and supervisors reviewing the DDAP Unusual Incident Reporting Policy 709.34(c)(4).
DDAP will be notified of all unusual incidents per 709.34(c)(4) within 72 hours following an unusual incident.
The compliance director will monitor compliance of all unusual incidents per standard 709.34(c)(4) on a daily basis.
Persons Responsible: Compliance Director, Division Director, Program Director.
Timeframe for Completion: July 19, 2017
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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.
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Observations
Based on a review of client records, the facility failed to document that services were provided consistent with the type and frequency specified in the individual treatment and rehabilitation plans in 3 of 10 client records.
Client #1 was admitted on 4/20/17 and was an active client at time of inspection. The individual treatment and rehabilitation plans completed on 5/5/17 and 6/8/17 specified that the client participate in individual therapy 1 time per week. However, based on the record of service, the lack of progress notes, and the lack of documented no-shows/cancellations from 5/24/17 through 6/20/17 reflected that the client did not attend any individual sessions.
Client #2 was admitted on 5/5/17 and was an active client at time of inspection. The individual treatment and rehabilitation plan completed on 5/21/17 specified that the client participate in group therapy 1 time per week. However, based on the record of service, the lack of progress notes, and the lack of documented no-shows/cancellations from 6/1/17 to 6/20/17 reflected that the client did not attend any group sessions.
Client #3 was admitted on 4/11/17 and was an active client at time of inspection. The individual treatment and rehabilitation plan completed on 5/11/17 specified that the client participate in group therapy 1 time per week. However, based on the record of service, the lack of progress notes, and the lack of documented no-shows/cancellations from 5/16/17 to 6/20/17 reflected that the client did not attend any group sessions.
Client #5 was admitted on 1/26/17 and was discharged 5/2/17. The individual treatment and rehabilitation plans completed on 3/1/17 and 4/1/17 specified that the client participate in group therapy 1 time per week. However, based on the record of service, the lack of progress notes, and the lack of documented no-shows/cancellations from 3/24/17 to 5/2/17 reflected that the client did not attend any group sessions.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A record-keeping training to include a review of treatment plans and records of service compliance will be facilitated on July 25, 2017 to ensure that all staff comply with the provision of counseling services standards per DDAPH Policy 709.52(c)
Adherence to this policy will be monitored during monthly Continuous Quality Improvement (CQI) meetings to ensure compliance.
Persons Responsible: Compliance Director, Division Director, Program Director.
Timeframe for Completion: July 25, 2017
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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
Based on a review of client records, the facility failed to provide a complete client record in 9 of 11 client records.
Client #2 was admitted on 5/5/17 and was still an active client at the time of the inspection. The client record did not contain any documentation of record of services as of the date of the inspection.
Client #3 was admitted on 4/11/17 and was still an active client at the time of the inspection. The client record did not contain any documentation of record of services as of the date of the inspection.
Client #4 was admitted on 8/2/16 and was discharged on 5/2/17. The client record did not contain any documentation of follow-up information as of the date of the inspection.
Client #5 was admitted on 1/26/17 and was discharged on 5/2/17. The client record did not contain any documentation of record of services as of the date of the inspection.
Client #6 was admitted on 2/24/17 and was discharged on 4/5/17. The client record did not contain any documentation of record of services as of the date of the inspection
Client #7 was admitted on 6/6/17 and was still an active client at the time of the inspection. The client record did not contain any documentation of record of services as of the date of the inspection.
Client #8 was admitted on 3/20/17 and was still an active client at the time of the inspection. The client record did not contain any documentation of record of services as of the date of the inspection.
Client #10 was admitted on 9/26/16 and was discharged on 2/22/17. The client record did not contain any documentation of follow-up information as of the date of the inspection.
Client #11 was admitted on 2/22/17 and was discharged on 3/16/17. The client record did not contain any documentation of follow-up information as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 7/19/17 the record of service in Clients Charts #2, #3, #7, and #8 were completed. Follow up's were completed on Client Chart's #4, #10, and #11.
A record-keeping training to include a review of record of service and follow up will be facilitated on July 25, 2017 to ensure that all staff adhere to Standard 709.53(a) Complete Client Record.
All record of services and client follow up will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) to ensure compliance of the standard.
Persons Responsible: Compliance Director, Division Director, Program Director.
Timeframe for Completion: July 25, 2017
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