INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 18, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Gaudenzia Focus 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(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of the policy and procedure manual On May 21-24, 2019, the facility failed to follow their policy in regards to completion of the assessment of staff training needs. The Plan for Assessing Staff Training Needs policy stated "The training plan shall be ready for implementation effective Jan. 31st of each year." The overall training plan for the project was not completed until May 16, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The relevent Gaudenzia Policy has been revised to state the "Program-level training needs assessment are due to the Training department by the end of January of each year. Upon receipt of the program-level annual assessment of staff training needs, the Director of Training and Education, in collaboration with the Project Director, will review the assessment in detail and develop a plan to address the training needs of the agency. The annual agency-wide training plan shall be ready for implementation no later than April 30th of each year." The Gaudenzia Director of Training and Education will ensure that this is completed within the designated time frame each year. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records on June 3, 2019, employee #1 was not trained in fire extinguisher use upon hire. Employee #1 was hired on March 4, 2019 and was still employed at the time of the inspection. There was no documentation that the employee received the training as of the date of this inspection June 18, 2019.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director completed this training on 6/7/2019 and documentation of this has been placed in his file. All relevant staff with the HR and Training department will review the DDAP 705.10 (c) (4)-705.28 (c) (4) regulations by 7/31/2019, and as the head of the Training department, the Director of Training and Education will be ultimately responsible for ensuring that all staff (to include administrative staff) receive required fire extinguisher training upon hire. Training department staff will review all staff files during the orientation process to ensure that this training is completed. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based upon a review of personnel records on June 3, 2019, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies. Employee #1 was hired on March 4, 2019 and was still employed at the time of the inspection. There was no documentation in employee #1 ' s personnel record indicating that the employee had been trained on what to do during emergencies as of the date of this inspection on June 18, 2019.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director completed this training on 6/7/19 and documentation of this has been placed in his file. All relevant staff within the HR and Training department will review DDAP 705.10 (d) (3) regulation by 7/31/19, and as the head of the Training department, the Director of Training and Education will be ultimately resposible for ensuring that all staff (to include administrative staff) recieve required emergency procedure training upon hire. Training department staff will review all staff files during the orientation process to ensure that this training is completed. |
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 seven client records on June 18, 2019, the facility failed to document a completed consent to release information in one record, prior to releasing information.
Client #4 was admitted on June 23, 2015 and discharged on May 2, 2019. An unusual incident report, dated November 19, 2018, stated that the client's family was contacted following an incident involving the client. At the time of the family contact, there was no consent to release information form on file for contact with any family members.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Regulation 709.28 (c)was reviewed with the Facility Director on 7/22/2019. All clients will be asked to sign disclosure information forms for any person involved in the client's care and any family or support persons identified by the client upon admission into the program, annually, and when new supports are identified. Both the facility Program Director Supervisor will monitor for completion of forms upon initial admission into program and via monthly chart audits to ensure ongoing compliance. |
709.30 (2) 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.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of seven client records on June 18, 2019, the facility's client's rights documentation, which is included in the orientation packet, failed to include all the required client rights. In seven of seven client records, the facility did not inform clients that they would not be discriminated against based on ethnicity, color, marital status or handicap.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director developed a written policy and procedure related to client's rights and developed a new form which now includes "clients cannot be discriminated against based on ethnicity, color, marital status, handicap, or disabilities". All current clients will sign and date the new updated "Client Bill of Rights" form by 8/8/19 and update annually. New admitted clients will sign the New Client Bill of Rights upon admission and the Program Director and Supervisor will audit charts upon admission and monthly to ensure new Client Bill of Rights forms are received, signed, dated, and updated annually. |
709.30 (3) 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.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on a review of seven client records on June 18, 2019, the facility's client's rights documentation, which is included in the orientation packet, failed to include all the required client rights, including that facility staff may limit access to their records if determined to be detrimental, and reason for removing sections of record shall be documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Continuous Improvement Director has revised the Gaudenzia Bill of Rights to accurately reflect the DDAP 709.30 regulations regarding a client's right to inspect their own record and actions they make take in this regard. The document now states that "The following rights are affirmed... The right to examine one's record within the guidelines approved by the agency in accrdance with Federal Regulations 42 CFR, and rebut any information in their record by inserting a counter statement clarification or correction. The agency may temporarily remove portions of the record prior to inspection if the Director determines that the information may detrimental if presented to the client. Reasons for removal of sections will be documented in the record. Clients have the right to appeal a decision limiting access to their records to the director.
Clients have the right to request the correction of inacurate, irrelevant, outdated or incomplete information in their records." This revised Bill of Rights document will be distributed to all programs by 7/26/2019. The Program Director will review it with all staff and it will be incorporated into the client orientation manuals and signed by all active clients by 8/2/2019. The Program Director will ensure that as a part of the regular, monthly CQI Chart Audit process, the current version of Client Bill of Rights is being completed. |
709.30 (4) 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.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on a review of seven client records on June 18, 2019, the facility's client's rights documentation, which is included in the orientation packet, failed to include all the required client rights, including that the client has a right to appeal a decision limiting access to their record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Continuous Quality Improvement Director has revised the Gaudenzia Client Bill of Rights to accurately reflect the DDAP 709.30 regulations regarding a client's right to inspect their own record and actions they make take in this regard. The document now states that, "The following rights are affirmed... The right to examine one's own record within the guidelines approved by the agency in accordance with Federal regulations 42 CFR, and rebut any information in their record by inserting a counter statement of clarification or correction. The agency may temporarily remove portions of the record prior to inspection if the Director determines that the information may be detrimental if presented to the client. Reasons for removal of sections will be documented in the record. Clients have the right to appeal a decision limiting access to their records to the director. Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records." This revised Bill of Rights document will be distributed to all programs by 7/26/19. The Program Director will review it with all staff and it will be incorporated into the client orientation manuals and signed by all active clients by 8/2/19. The Program Director will ensure that as a part of the regular, monthly CQI Chart Audit process, the current version of the Client Bill of Rights is being completed. |
709.30 (5) 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.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Based on a review of seven client records on June 18, 2019, the facility's client's rights documentation, which is included in the orientation packet, failed to include all the required client rights, including that the client has the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Continuous Quality Improvement Director has revised the Gaudenzia Client Bill of Rights to accurately reflect the DDAP 709.30 regulations regarding a client's right to inspect their own record and actions they make take in this regard. The document now states that, "The following rights are affirmed... The right to examine one's own record within the guidelines approved by the agency in accordance with Federal regulations 42 CFR, and rebut any information in their record by inserting a counter statement of clarification or correction. The agency may temporarily remove portions of the record prior to inspection if the Director determines that the information may be detrimental if presented to the client. Reasons for removal of sections will be documented in the record. Clients have the right to appeal a decision limiting access to their records to the director. Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records." This revised Bill of Rights document will be distributed to all programs by 7/26/19. The Program Director will review it with all staff and it will be incorporated into the client orientation manuals and signed by all active clients by 8/2/19. The Program Director will ensure that as a part of the regular, monthly CQI Chart Audit process, the current version of the Client Bill of Rights is being completed. |
709.71(a)(1) LICENSURE Admission criteria
709.71. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(1) Criteria for admission.
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Observations
Based on a review of facility's policy and procedure manual on May 21-24, 2019, the facility failed to develop a written plan specific to transitional living facilities for providing intake and admission criteria.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Continuous Quality Improvement Director will collaborate with the Program Director to develop a Gaudenzia policy which specifies the admission criteria of the program in accordance with the DDAP regulations for Transitional Living Facilities. This revised Policy will be completed and distributed to all programs by 8/16/19. The Program Director will review it with all staff in a staff meeting by 8/30/19. The Program Director will ensure that the policy is adhered to. |
709.71(a)(2) LICENSURE Completion Guidelines
709.71. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(2) Guidelines for completion of residency.
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Observations
Based on a review of facility's policy and procedure manual on May 21-24, 2019, the facility failed to develop a written plan specific to transitional living facilities for providing intake and admission guidelines for completion of residency.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Continuous Quality Improvement Director will collaborate with the Program Director to develop a Gaudenzia policy which specifies the completion guidelines of the program in accordance with the DDAP regulations for Transitional Living Facilities. This revised Policy will be completed and distributed to all programs by 8/16/19. The Program Director will review it with all staff in a staff meeting by 8/30/19. The Program Director will ensure that the policy is adhered to. |
709.71(a)(3) LICENSURE Termination criteria
709.71. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(3) Involuntary discharge/termination criteria.
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Observations
Based on a review of facility's policy and procedure manual on May 21-24, 2019, the facility failed to develop a written plan specific to transitional living facilities for providing intake and admission criteria for involuntary discharge/termination.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Continuous Quality Improvement Director will collaborate with the Program Director to develop a Gaudenzia policy which specifies the termination guidelines of the program in accordance with the DDAP regulations for Transitional Living Facilities. This revised Policy will be completed and distributed to all programs by 8/16/19. The Program Director will review it with all staff in a staff meeting by 8/30/19. The Program Director will ensure that the policy is adhered to.
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