INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the June 19-21, 2017 licensure renewal inspection. The follow-up inspection was conducted on October 2, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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 the review of 4 client records, every client record reviewed had consent to release forms that were missing elements. Additionally, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in 1 record.
Client # 1 was admitted on 8/8/17 and was discharged on 8/24/17. There was a consent to release information form signed and dated on 8/8/17 to funding source, however, the form did not include the purpose of disclosure or the specific information to be disclosed.
Client # 2 was admitted on 8/23/17 and was discharged on 9/10/17. A consent to release information form was signed and dated on 8/11/17 to the funding source, however, the form did not include the purpose of disclosure or the specific information to be disclosed.
Client # 3 was admitted on 8/31/17 and was discharged on 9/14/17. A consent to release information form was signed and dated on 8/31/17, however, the form did not include the name of a person, agency or organization to whom disclosure was being made, the purpose of disclosure or the specific information to be disclosed. Additionally, there was documentation that the facility was billing 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 8/28/17 and was an active client at the time of the inspection. A consent to release information form was signed and dated on 8/28/17 to the funding source, however, there was no dated witness signature.
*The plan of correction from the 06/21/2017 annual licensing inspection, submitted and approved on 07/20/2017, stated that the corrective action plan would be completed by 07/25/2017.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Client #1, #2, #3, and #4 were discharged at the time that the DDAP POC was due.
A record-keeping retraining to include a review of confidentiality standards will be facilitated on November 13, 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: November 13, 2017 |
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 4 client records, each record 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.
*The plan of correction from the 06/21/2017 annual licensing inspection, submitted and approved on 07/21/2017, stated that the corrective action plan would be completed by 07/25/2017.
These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
On 7/19/17 we revised the intake package to ensure that all Client Rights Forms are congruent.
A record-keeping retraining to include a review of client rights standards will be facilitated on November 13, 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: November 13, 2017 |
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 October 2, 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 September 13, 2017.
*The plan of correction from the 06/21/2017 annual licensing inspection, submitted and approved on 07/20/2017, stated that the corrective action plan would be completed by 07/19/2017.
These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
The DDAP Unusual Incident Report was originally sent on September 14, 2017 and was resent on October 31, 2017.
An In Service Training will be conducted on November 13, 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: November 13, 2017 |
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 1 of 2 client records.
Client #3 was admitted on 8/31/17 and was discharged on 9/14/17. The preliminary treatment and rehabilitation plan completed on 9/2/17 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 9/2/17 through 9/14/17 reflected that the client did not attend any individual sessions.
*The plan of correction from the 06/21/2017 annual licensing inspection, submitted and approved on 07/20/2017, stated that the corrective action plan would be completed by 07/25/2017.
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 November 13, 2017 to ensure that all staff comply with the provision of treatment planning and individual counseling services standards per DDAP 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: November 13, 2017 |