INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 28, 2015 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. 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 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the fire drill logs, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings include:
A review of the June, 2014 through May, 2015 fire drill logs were conducted on May 28, 2015. During every month reviewed, the facility conducted two fire drills per month and during every drill conducted the facility failed to use alternate exit routes. The exit route used for all of the drills during that timeframe was the door exit route only.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, monthly fire drills will be conducted at the facility and alternate exit routes will be used during fire drills. The fire escape will be scheduled as an alternate exit route when conducting fire drills. The Clinical Supervisor will ensure that the facility meets this requirement. Fire drill grids will be reviewed monthly by Administrative Manager for compliance. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on a review of 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 five of ten records reviewed.
The findings included:
4 Pa. Code states:
Information released to judges, probation or parole officers, insurance company, health or hospital plan or governmental officials, pursuant to paragraphs (1), (2), (4),(7), (8) or subsection (a) of this section, is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following.
(1) Whether the client is or is not in treatment.
(2) Client's prognosis.
(3) The nature of the project.
(4) A brief description of the client's progress.
(5) A short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse.
Ten client records requiring proper releases of information were reviewed on May 28, 2015. The facility failed to stay within the limits imposed by 4 Pa. Code 255.5 (b) in client records, #2, 6, 7, 8, and 9.
Client #2 was admitted to treatment on December 14, 2014 and was still an active client at time of the inspection. A release of information form to the probation officer was signed on 12/19/14 and allowed for the disclosure of the urinalysis results, which exceeded 255.5.
Client #6 was admitted to treatment on May 20, 2014 and was discharged on November 4, 2014. A release of information form to the probation officer was signed on 05/27/14 and allowed for the disclosure of the urinalysis results, which exceeded 255.5. Additionally, a release of information form to a government agency was signed on 05/20/14 and allowed for the disclosure of the first and last page of the Biopsychosocial, which exceeded 255.5.
Client #7 was admitted to treatment on October 28, 2014 and was discharged on February 23, 2015. A release of information form to a government agency was signed on 10/28/14 and allowed for the disclosure of the first and last page of the Biopsychosocial, which exceeded 255.5.
Client #8 was admitted to treatment on July 1, 2014 and was discharged on February 10, 2015. A release of information form to a government agency was signed on 08/08/14 and allowed for the disclosure of the first and last page of the Biopsychosocial, which exceeded 255.5.
Client #9 was admitted to treatment on June 11, 2014 and was discharged on December 2, 2014. A release of information form to a government agency was signed on 06/11/14 and allowed for the disclosure of the first and last page of the Biopsychosocial, which exceeded 255.5.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An all staff in service training was held on June 19, 2015 to address clinical staff on treatment management procedures specific to confidentiality PA 255.5. The five allowable points were reviewed in detail as well as were distributed to all staff. Time was allotted for questions and scenario review. The Clinical Supervisor will review releases for compliancy during the CQI process monthly. Clinical staff will be monitored monthly in regular supervisory sessions.
Client charts 2, 6, 7, 8 & 9 are unable to be brought up to compliance. All five have been discharged.
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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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on the review of client records, the facility failed to ensure that an informed and voluntary consent to release information was obtained in one of ten client records reviewed.
The findings included:
Ten client records requiring complete informed and voluntary consent to release information forms were reviewed on May 28, 2015. The facility failed to ensure that an informed and voluntary consent to release information form was obtained in client record, #10.
Client #10 was admitted to treatment on July 25, 2014 and was discharged on February 10, 2015. A progress report, within the limits of Pa Code 255.5, to an attorney was signed and dated on 11/19/14; however, the facility failed to obtain an informed and voluntary consent to release information form from the client prior to the disclosure of the progress report.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An all staff in service training was held on June 19, 2015 to address clinical staff on treatment management procedures specific to confidentiality PA 255.5. The five allowable points were reviewed in detail as well as were distributed to all staff. Time was allotted for questions and scenario review. Clinicians were directed to not release information to anyone without the appropriate release. The Clinical Supervisor will review releases for compliancy during the CQI process monthly. Clinical staff will be monitored monthly in regular supervisory sessions
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document treatment and rehabilitation plan updates at least every 60 days in two of ten client records reviewed.
The findings include:
Ten client records were reviewed on May 28, 2015. Nine client records required at least one treatment and rehabilitation plan update. The facility failed to document treatment and rehabilitation plan updates at least every 60 days in client records, #5 and 7.
Client #5 was admitted into treatment on June 3, 2014 and was discharged on October 9, 2014. The comprehensive treatment and rehabilitation plan was signed/dated on 07/03/2014 and a treatment plan update was due no later than 09/03/2014; however, there was no treatment plan update documented in the client record as of the date of the inspection.
Client #7 was admitted into treatment on October 28, 2014 and was discharged on February 23, 2015. The comprehensive treatment and rehabilitation plan was signed/dated on 11/24/2014 and a treatment plan update was due no later than 01/24/2015; however, there was no treatment plan update documented in the client record 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
An all staff in service training will be held on June 19, 2015 to address clinical staff on treatment management procedures specific to the treatment plan update process. All staff will be directed to update treatment plans every 60 days or sooner. The Clinical Supervisor will review treatment plans for compliancy during the CQI process monthly. Clinical staff will be monitored monthly in regular supervisory sessions |
709.93(a) 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:
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Observations
Based on a review of client records, the facility failed to document a complete client record on an individual, which includes case consultation notes, in two of six complete client records reviewed.
The findings include:
Ten client records were reviewed on May 28, 2015. Six of the ten client records were discharged clients and required case consultation notes documented in the client record. The facility did not provide a complete client record in records, # 6 and 9.
Client #6 was admitted to treatment on May 20, 2014 and was discharged on November 4, 2014. A case consultation was due no later than August 20, 2014; however, there was no case consult documentation in the client record as of the date of the inspection.
Client #9 was admitted to treatment on June 11, 2014 and was discharged on December 2, 2014. A case consultation was due no later than September 11, 2014; however, there was no case consult documentation in the client record 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
An all staff in service training was held on June 19, 2015 to address clinical staff on treatment management procedures specific to case consults. Timelines were reviewed stating a case consult is due every 90 days or sooner, as well as two or more clinical signatures are required to make it a valid consult. Staff were directed to bring due case consults to weekly clinical meeting. The Clinical Supervisor will review charts for compliancy during the CQI process monthly. Clinical staff will be monitored monthly in regular supervisory sessions
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709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
Based on a review of client records, the facility failed to document a physician signature on the individual treatment plans for medical assistance clients in two of of ten client records.
The findings included:
Ten client records were reviewed on May 28, 2015. Five of the ten client records were required to have a physician signature on the individual treatment plans. The individual treatment plans contained in client records, #2 and 8 did not contain a physician signature.
Client #2 was admitted to treatment on December 19, 2014 and was still an active client at the time of the inspection. Client #2 was identified as a Medical Assistance client. The individual treatment and rehabilitation plan that was in the chart was not signed/dated by the client nor the physician. Additionally, there was a treatment plan update completed on 03/19/15 that did not include a physician signature.
Client #8 was admitted to treatment on July 1, 2014 and was discharged on February 10, 2015. Client #8 was identified as a Medical Assistance client. The individual treatment and rehabilitation plan updates conducted on 09/29/14 and 12/12/14 did not include a physician signature.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Effective May 29, 2015 all outpatient charts will be reviewed on a monthly basis specifically focusing on obtaining physician signature on all treatment plans. Administrative staff will review charts monthly to ensure compliance through the CQI process.
Client # 2 was discharged ASA on 6-12-15 prohibiting the completion of documents to include client and physician signatures. |