INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on October 29, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, Gaudenzia, Inc. Winner Co-Occurring Women and Children 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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705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
The facility failed to ensure that the hot water temperature did not exceed 120 degrees Fahrenheit. Based on a physical plant inspection, the hot water temperature in the toddler bathroom, located in the childcare room, was measured at 127 degrees Fahrenheit and the hot water temperature in the adult bathroom, also located in the childcare room, was measured at 128 degrees Fahrenheit.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 10/30/2020, the Maintenance Department adjusted the hot water temperature to not exceed 120°. Going forward, the Housing Manager Supervisor or designee will conduct water temperature checks twice a week. |
705.11 (2) (ii) LICENSURE Child care.
705.11. Child care.
(2) Interior space. The residential facility shall:
(ii) Maintain security screens or safety locks for all operable windows.
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Observations
The facility failed to maintain security screens for all operable windows. Based on a physical plant inspection, there was one window in Room Three that was missing the security screen.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 11/17/2020, the Maintenance Department inserted a security window screen in room 3. Going forward, the Housing Manager Supervisor or designee will ensure that windows have window screens during weekly facility checks. |
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
The project failed to obtain an informed and voluntary consent to release information form from the client for the disclosure of information contained in the client record in three of seven client records reviewed.
Client #1 was admitted on March 24, 2020 and was a current client at the time of the inspection. There was evidence that the client's funding source was billed for services; however, there was no consent for the disclosure of information documented prior to the disclosures. Additionally, there was documented communication between facility staff and a friend of the client on June 30, 2020; however, there was no consent form documented prior to the disclosure.
Client #3 was admitted on August 10, 2020 and was a current client at the time of the inspection. There was evidence that the client's funding source was billed for services; however, there was no consent form documented prior to the disclosures.
Client #4 was admitted on October 8, 2019 and was discharged on December 23, 2019. There was documented communication between facility staff and a government agency on November 13, 2020; however, there was no consent form documented prior to the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will conduct inservice training with the clinical team on 11/24/2020 regarding the completion of the Confidentiality Release/Request Forms. Moving forward all client documentation will be reviewed by the Program Director or designee weekly to ensure consents are appropriately completed. Additionally, CQI/Compliance Department will conduct quarterly clinical chart audits ensuring that documentation/consents are completed appropriately.
All active client records, including those listed in the deficiency, will be reviewed to ensure that the appropriate disclosure consents (for individuals and entities involved in the clients' care) are completed and signed by the client by 11/24/20.
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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
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 six of seven client records reviewed.
Client #1 was admitted on March 24, 2020 and was a current client at time of the inspection. A release of information form to a government agency, signed and dated by the client on May 27, 2020, that allowed for the release of treatment plans, case consultations, mental health records, discharge summary, progress notes and assessments, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #2 was admitted on July 10, 2020 and was a current client at the time of the inspection. A release of information form to the funding source, signed and dated by the client on July 11, 2020, that allowed for the release of psychological and psychiatric evaluations, treatment plans, case consults, mental health records, physical and medical records, discharge summary, progress notes, medication records and assessments, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #4 was admitted on October 8, 2019 and was discharged on December 23, 2020. A release of information form to the funding source, signed and dated by the client on October 9, 2019, that allowed for the release of psychological and psychiatric evaluations, treatment plans, case consults, mental health records, physical and medical records, discharge summary, progress notes, medication records and assessments, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #5 was admitted on January 12, 2020 and was discharged on March 9, 2020. A release of information form to the funding source, signed and dated by the client on January 16, 2020, that allowed for the release of treatment plans, mental health records, discharge summary, progress notes, medication records and assessments, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #6 was admitted on December 12, 2019 and was discharged on March 31, 2020. A release of information form to the funding source, signed and dated by the client on January 22, 2020, that allowed for the release of treatment plans, case consults, mental health records, discharge summary, progress notes, medication records and assessments, all of which exceeds the limits established by 4 Pa. Code 255.5. Additionally, a release of information form to a probation offic, signed and dated by the client on January 22, 2020, that allowed for the release of treatment plan and progress notes, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #7 was admitted on January 6, 2020 and was discharged on July 16, 2020. A release of information form to the funding source, signed and dated by the client on January 21, 2020, that allowed for the release of psychological and psychiatric evaluations, treatment plans, case consults, mental health records, physical and medical records, discharge summary, progress notes, medication records and assessments, all of which exceeds the limits established by 4 Pa. Code 255.5.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will conduct an inservice meeting with the clinical team on 11/24/2020 regarding the limitations of confidentiality when completing the disclosure consents. Moving forward, all client documentation, including the disclosure consents will be reviewed by the Program Director or designee weekly to ensure consents are appropriately completed. Additionally, CQI/Compliance Department or designee weekly to ensure consents are appropriately completed.
All disclosure consents for all active clients, including those listed in the deficiency, will be reviewed to ensure that the consents do not exceed the limits established by 4 Pa. Code 255.5. Consents identified to exceed the limits will be identified as not valid in the record and new disclosure consents will be completed within required limits by 11/24/2020
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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
The project failed to file a written unusual incident report with the Department within three business days following five unusual incidents, all involving the presence of police, fire, or ambulance personnel at the facility.
On February 9, 2020, ambulance personnel responded to the facility and transported a client to the hospital. There is no documentation that this unusual incident was reported to the Department within the regulatory timeframe.
On February 24, 2020, law enforcement responded to the facility. There is no documentation that this unusual incident was reported to the Department within the regulatory timeframe.
On March 7, 2020, ambulance personnel responded to the facility and transported a client to the hospital. There is no documentation that this unusual incident was reported to the Department within the regulatory timeframe.
On March 20, 2020, ambulance personnel responded to the facility and transported a client to the hospital. There is no documentation that this unusual incident was reported to the Department within the regulatory timeframe.
On May 27, 2020, ambulance personnel responded to the facility and transported a client to the hospital. There is no documentation that this unusual incident was reported to the Department within the regulatory timeframe.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will conduct an inservice with the clinical team on 11/24/2020 regarding the completion and submission of reportable incidents to DDAP. Moving forward, the Program Director will review all incident reports within 24 hours to ensure that the reports are appropriately completed and submitted per regulations. All incident reports will be reviewed on a monthly basis during the Eastern Region CQI meeting. Additionally, the Compliance Department will conduct quarterly incident review analyses. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
The project failed to ensure that treatment and rehabilitation plans were reviewed and updated at least every 30 days in two of seven client records reviewed.
Client #1 was admitted on March 24, 2020 and was a current client at time of inspection. A treatment plan update was completed on June 17, 2020 and the next update was due no later than July 17, 2020; however, the update was not documented until August 10, 2020. Additionally, the next update was then due no later than September 10, 2020; however, the update was not documented until September 26, 2020.
Client #7 was admitted on January 6, 2020 and was discharged on July 16, 2020. A treatment plan update was completed on February 20, 2020 and the next update was due no later than March 20, 2020; however, the update was not documented until April 1, 2020. Additionally, a treatment plan update was completed on May 6, 2020 and the next update was due no later than June 6, 2020; however, the update was not documented until July 1, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Supervisor will conduct an inservice with the clinical team on 11/19/2020 regarding the completion and submission of treatment plan reviews. Moving forward, the Program Director or designee will review all treatment plan updates upon completion to ensure timely submission. All treatment plan updates will be reviewed on a monthly basis during the Eastern Region CQI meeting. Additionally, the Compliance Department will conduct quarterly treatment plan review analyses. |
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
The project failed to assure that counseling services are provided to the client according to the individual treatment and rehabilitation plan in three of seven client records reviewed.
Client #1 was admitted on March 24, 2020 and was a current client at time of inspection. The comprehensive treatment plan, completed on April 4, 2020, indicated that the client was to receive one individual counseling session per week; however, there was no documentation that the client received individual counseling sessions for weeks of May 10, 2020 through May 16, 2020, July 5, 2020 through July 11, 220, July 19, 2020 through July 25, 2020 and August 9, 2020 through August 15, 2020.
Client #2 was admitted on July 10, 2020 and was a current client at the time of the inspection. The comprehensive treatment plan, completed on August 13, 2020, indicated that the client was to receive one individual counseling session per week; however, there was no documentation that the client received individual counseling sessions for weeks of July 19, 2020 through July 25, 2020, July 26, 2020 through August 1, 2020, August 9, 2020 through August 15, 2020, September 6, 2020 through September 12, 2020 and October 11, 2020 through October 17, 2020.
Client #3 was admitted on August 10, 2020 and was a current client at the time of the inspection. The comprehensive treatment plan, completed on September 8, 2020, indicated that the client was to receive one individual counseling session per week; however, there was no documentation that the client received individual counseling sessions for weeks of October 4, 2020 through October 10, 2020 and October 11, 2020 through October 17, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Supervisor will conduct an inservice with the clinical team on 11/19/2020 regarding required individual counseling sessions submissions. As of 12/01/20, counselors will develop a set schedules for individual sessions, developed by the counselor and the client. Additionally, counselors will post session schedules as a reminder to clients. When a client does not attend, "no-show" to a scheduled appointment, the counselor will document it in the Electronic Health Records, and reschedule session within the week. EHR will be monitored weekly by Program Supervisor to ensure sessions are being documented. Lastly, quarterly audits will be conducted by the CQI/Compliance Department. |
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
The project failed to document, in the client's complete record, verification that any work done by the client at the project is an integral part of his/her treatment and rehabilitation plan in seven of seven client records reviewed.
Client #1 was admitted on March 24, 2020 and was a current client at time of inspection.
Client #2 was admitted on July 10, 2020 and was a current client at the time of the inspection.
Client #3 was admitted on August 10, 2020 and was a current client at the time of the inspection.
Client #4 was admitted on October 8, 2019 and was discharged on December 23, 2020.
Client #5 was admitted on January 12, 2020 and was discharged on March 9, 2020.
Client #6 was admitted on December 12, 2019 and was discharged on March 31, 2020.
Client #7 was admitted on January 6, 2020 and was discharged on July 16, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All active client treatment plans will be reviewed to ensure that work therapy including child care is prescribed in the client's treatment plan by 11/20/2020. Moving forward, the Program Director or Program Supervisor will review and approve all initial treatment plans and treatment plan reviews upon completion to ensure timely submission to ensure that work therapy including child care is appropriately prescribed in the client's treatment plan. Additionally, CQI/Compliance Department will conduct quarterly clinical chart audits ensuring work therapy/child care in included in the treatment plans.
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