INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 20 - 24, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Erie Inc. Edinboro Satellite Office 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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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to document fire extinguisher training was completed upon staff employment in one of one personnel record.
Employee # 5 was hired May 10, 2021. Fire extinguisher training was not documented until August 19, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This staff member has since completed the Fire Extinguisher training on 8/19/2021.
Going forward, staff will complete all required trainings within the required timeframes. This will be monitored by the Program Director on at least a quarterly basis through review of staff training files.
Additionally, the Compliance department will conduct a review of all Plans of Correction within 9 months to ensure full implementation.
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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill records, the facility failed to document monthly fire drills from April 2020 through July 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
These drills were not conducted because the facility was not being used during this period due to the pandemic.
Going forward, fire drills will be conducted according to DDAP licensing standards, and when necessary, a waiver will be obtained to allow for any deviation from this practice.
The Program Director will review fire drill logs on a monthly basis, and the Quality Assurance department will conduct at least Quarterly reviews to ensure adherence to DDAP standards.
Additionally, the Compliance department will conduct a review of all Plans of Correction within 9 months to ensure full implementation.
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705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to document that all personnel on all shifts were trained to perform assigned tasks during emergencies in one of one personnel record.
Employee # 5 was hired May 10, 2021. Emergency training was not documented for employee # 5 upon employment for their assigned shift.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This staff member has since completed the Fire Safety training on 8/19/2021.
Going forward, staff will complete all required trainings within the required timeframes. This will be monitored by the Program Director on at least a quarterly basis through review of staff training files.
Additionally, the Compliance department will conduct a review of all Plans of Correction within 9 months to ensure full implementation.
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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 client records, the facility failed to document a written, informed and voluntary consent from the client prior to the disclosure of information contained in the client record in five of five records.
A prior authorization for drug and alcohol treatment services was obtained from the funding entity without written consent from the client during the intake process.
Client # 1 was admitted June 16, 2021. In addition, a treatment progress update was faxed to the probation officer on July 23, 2021 without the written consent of client # 1.
Client # 2 was admitted June 16, 2021.
Client # 3 was admitted March 3, 2021 and discharged May 19, 2021.
Client # 4 was admitted June 22, 2021 and discharged July 13, 2021. In addition, a treatment progress update was faxed to the probation officer on July 8, 2021 without the written consent of client # 4.
Client # 5 was admitted September 23, 2020 and discharged January 23, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Consents reviewed indicated verbal consent.
All staff have been trained regarding the requirement to obtain an informed and voluntary consent from the client for the disclosure of information with either written or electronic signature. This training will occur on 10/29/2021.
For any clients who are still active with the program, updated consents will be completed to include all required items.
The Program Director will monitor to ensure compliance through monthly audits of clinical records, and follow up on any inconsistencies in clinical supervision sessions.
The Quality Assurance department will conduct quarterly program review, and the Compliance department will review the plan of correction at least annually to ensure implementation.
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709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document an informed and voluntary consent from the client that included the dated signature of the client in five of five client records.
Consents were documented during the intake process in the following client records.
Client # 1 was admitted June 16, 2021. Consents for insurance, probation, emergency contact, lab and a government agency did not include the dated signature of the client.
Client # 2 was admitted June 16, 2021. Consents for insurance, probation, emergency contact, lab and a government agency did not include the dated signature of the client.
Client # 3 was admitted March 3, 2021 and discharged May 19, 2021. Consents for insurance, probation, emergency contact, lab and a government agency did not include the dated signature of the client.
Client # 4 was admitted June 22, 2021 and discharged July 13, 2021. Consents for insurance, probation, emergency contact, lab and a government agency did not include the dated signature of the client.
Client # 5 was admitted September 23, 2020 and discharged January 23, 2021. Consents for insurance, lab and a government agency did not include the dated signature of the client.
The findings were reviewed with staff during the licensing process.
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Plan of Correction
Consents reviewed indicated verbal consent.
All staff have been trained regarding the requirement to obtain an informed and voluntary consent from the client for the disclosure of information with either written or electronic signature. This training will occur on 10/29/2021.
For any clients who are still active with the program, updated consents will be completed to include all required items.
The Program Director will monitor to ensure compliance through monthly audits of clinical records, and follow up on any inconsistencies in clinical supervision sessions.
The Quality Assurance department will conduct quarterly program review, and the Compliance department will review the plan of correction at least annually to ensure implementation.
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709.93(a)(11) LICENSURE Client records
709.93. 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow-up information within seven days of discharge, per facility policy, in one of three client records.
Client # 4 was admitted June 22, 2021 and discharged July 13, 2021. No follow-up information was documented in client record # 4.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Follow up information will be documented for all clients post-discharge. A log of follow up will be maintained on-site.
All staff have been trained regarding the requirement to document follow-up information. A training will occur on 10/29/2021 to review requirements.
The Program Director will monitor to ensure compliance through monthly audits of clinical records and the follow-up log. The Program Director will follow up on any inconsistencies in supervision sessions.
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