INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 10, 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 Washington 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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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on the review of personnel records, staff schedules and the Staffing Requirement Facility Summary Report, the project failed to ensure that at least one person trained in CPR and first aid was onsite during the project's hours of operation.
On May 5, 2021, there was no staff member with a current CPR/First Aid Certification onsite between the hours of 5:00pm and 9:30pm.
On May 24, 2021, there was no staff member with a current CPR/First Aid Certification onsite between the hours of 7:30am and 8:30am.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Division Director has completed a thorough review of all staff training requirements and all staff in need of CPR/First Aid training are scheduled for re-certification on 07/16/2021. In addition, the Division Director has amended the schedule to ensure that staff with CPR/First Aid training are available on all shifts. The Program Director will also review training requirements on a monthly basis to ensure that all staff trainings are up to date. |
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 project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in four of seven client records reviewed.
Client #2 was admitted on April 1, 2021 and was a current client at the time of the inspection. On April 26, 2021, there is documentation in the client ' s record of a family counseling session conducted with a client ' s family member; however, there was no release of information for this family member documented in the client ' s record at the time of the inspection.
Client #4 was admitted on November 10, 2021 and was discharged on January 21, 2021. On January 18, 2021, there is documentation in the client ' s record of a referral made to another treatment facility by staff; however, there was no release of information for this treatment facility documented in the client ' s record at the time of the inspection.
Client #5 was admitted on December 2, 2020 and was discharged on February 8, 2021. On December 11, 2020 and December 17, 2020, there is documentation in the client ' s record of communication occurring between staff and a court official; however, there was no release of information for this court official documented in the client ' s record at the time of the inspection.
Client 7 was admitted on February 4, 2021 and was discharged on May 6, 2021. On February 22, 2021, there is documentation in the client ' s record of a meeting occurring with staff and the client ' s case manager; however, there was no release of information for this case manager documented in the client ' s record at the time of the inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Program Director will review Confidentiality and Releases of Information with all staff during staff in-service by 07/30/2021. In addition, the Program Director will monitor confidential releases of information during monthly file audits and address discrepancies during staff supervisions. The CQI department will monitor confidentiality and releases of information during quarterly CQI file audits and will report findings to the Program Director. In regards to the release of information for Client #2 will be obtained for the family session dated 4/26/21 by 07/16/21. All other clients have been discharged. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the project failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in two of seven client records reviewed.
Client #1 was admitted on March 23, 2021 and was an active client at the time of the inspection. A release of information form to the funding source, signed and dated by the client on March 23, 2021, allowed for the release of progress notes and treatment plans, all of which exceeds the limits established by 4 Pa. Code 255.5. Additionally, a release of information form to a government agency, signed and dated by the client on March 29, 2021, did not document the specific information to be disclosed.
Client 7 was admitted on February 4, 2021 and was discharged on May 6, 2021. A release of information form to the funding source, signed and dated by the client on February 4, 2021, allowed for the release of psychological/psychiatric evaluations, case consultations, the discharge summary assessments and treatment plans, all of which exceeds the limits established by 4 Pa. Code 255.5.
These findings were reviewed with project staff during the licensing process.
This is a repeat citation from last year's licensure renewal inspection.
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Plan of Correction
The Program Director will review Confidentiality and Releases of Information with all staff during staff in-service by 07/30/2021.
In addition, the Program Director will monitor confidential releases of information during monthly file audits and address discrepancies during staff supervisions.
The CQI department will monitor confidentiality and releases of information during quarterly CQI file audits and will report findings to the Program Director.
The release of information for Client #1 dated March 23, 2021 for the funding source and the release dated March 29, 2021 for a government agency have been "revoked" and new releases for both will be completed by 07/30/2021.
All other clients have been discharged.
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709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the purpose of disclosure in one of seven client records reviewed.
Client #4 was admitted on November 10, 2021 and was discharged on January 21, 2021. A release of information form for a medical center, signed and dated by the client on January 18, 2021, did not document the purpose of disclosure.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Program Director will review Confidentiality and Releases of Information with all staff during staff in-service by 07/30/2021.
In addition, the Program Director will monitor confidential releases of information during monthly file audits and address discrepancies during staff supervisions.
The CQI department will monitor confidentiality and releases of information during quarterly CQI file audits and will report findings to the Program Director.
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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 unusual incident log, the project failed to file a written unusual incident report with the Department within three business days following an unusual incident involving an event at the facility requiring the presence of police, fire or ambulance personnel.
On April 18, 2021, the fire department responded to the facility; however, there was no documentation that an unusual incident report was ever filed with the Department.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Plan of Correction:
The Program Director has reviewed and forwarded all unusual incident reports noted.
The Program Director will review the incident log on a weekly basis to ensure that all reports are sent to the Department within 3 days. In addition, on a quarterly basis the CQI Department will review the incident log to ensure compliance and report findings to the Program Director.
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