INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 21, 2017 through June 23, 2017 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 Together 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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704.9(b) LICENSURE Performance evaluation
704.9. Supervision of counselor assistant.
(b) Performance evaluation. The counselor assistant shall be given a written semiannual performance evaluation based upon measurable performance standards. If the individual does not meet the standards at the time of evaluation, the counselor assistant shall remain in this status until the supervised period set forth in subsection (c) is completed and a satisfactory rating is received from the counselor assistant's supervisor.
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Observations
Based on a review of ten personnel records on 06/21/17, the facility failed to ensure that counselor assistant personnel records contained documentation of a semiannual written individual performance evaluation for employee record # 10, who was hired as a counselor assistant on 2/10/16 and was still in the postion at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A training will be facilitated on July 25, 2017 with all clinical supervisory staff to inform them and assure that counselor assistants are supervised and given semiannual evaluations as indicated by DDAP Standard 704.9(b) Performance Evaluation.
The program Director with assistance from Gaudenzia's Human Resource Department will monitor compliance of Standard 704.9(b) Performance Evaluation.
Timeframe for Completion: July 25, 2017 |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection on June 20, 2017 at approximately 02:00 P.M., it was observed that the facility failed to ensure privacy of group counseling sessions as a group was being conducted on the third floor with the group room door open. During a second physical plant inspection on June 22, 2017 at approximately 10:45 A.M., a group counseling session was being conducted with the door open on the third floor.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A training to ensure privacy and confidentiality during counseling sessions will be facilitated on July 25, 2017 to ensure that all staff adhere to Standard 705.4(3) Counsling Areas.
The program director and supervisors will monitor daily compliance to Standard 705.4(3).
Persons Responsible: Compliance Director, Division Director, Program Director and Supervisors.
Timeframe for Completion: July 25, 2017
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705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on the physical plant inspection on June 23, 2017 at approximately 01:40 P.M, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times as mold and mildew were observed in 2 shower stalls in the bathroom on the fourth floor.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 6/26/17 the remaining mold and mildew in the shower was removed after being power-washed. After the shower was cleaned it was re-chalked. Another maintenance request was put in on July 14, 2017 to have all of the shower's power washed and cleaned on a monthly basis.
The program staff and maintenance department will monitor the cleanliness of the bathrooms and the members will continue with the weekly General Inspection (GI) of their living areas which includes the bathrooms.
Persons Responsible: Division Director, Program Director and Maintenance Supervisor.
Timeframe for Completion: July 14, 2017
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709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
Based on the physical plant inspection conducted on June 20, 2017, it was discovered that the facility failed to maintain client records in locked storage containers at all times. Several boxes of unattened client records were unsecured in a hallway on the fourth floor. The same boxes were also observed unattended in the hallway on June 22, 2017 at approximately 10:30 A.M., and again on June 23, 2017 at approximately 01:50 P.M.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On June 20, 2017 the boxes that were in the 4th floor hallway were moved to a secure locked area.
The program supervisor will ensure that all client records will be secured in locked storage file cabinets per Standard 709.28(b). We will review the policy with the staff during an In-Service Training on July 25, 2017.
Persons Responsible: Division Director, Program Director.
Timeframe for Completion: July 25, 2017
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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 ten client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in client record #'s 7, 8, 9, and 10. Additionally, client record #'s 8 and 10 had consent to release information forms that were missing required components.
Client #7 was admitted on 11/30/16 and discharged on 01/18/17. The record documented a family session on 12/05/16, but did not contain a consent to release information form to the involved family member. The record also contained documentation of correspondence with two individuals outside of the agency, one of which disclosed presence in treatment and the other disclosed the physical exam, psychiatric exam, drug and alcohol history, mini mental status exam, and medications. However, the record did not contain consent to release information forms for either of the individuals.
Client #8 was admitted on 04/19/17 and was discharged on 06/13/17. The record did not contain a consent to release information form to the funding source at the time of the inspection and there was evidence of the disclosure of billing information. Additionally, the record contained a consent to release information form that was not dated by the client, and did not include the name, agency, or organization to which the disclosure would be made. The record also contained a consent to release information form that did not contain an expiration date or condition of expiration.
Client #9 was admitted on 05/08/17 and was an active client at the time of the inspection. The record did not contain a consent to release information form to the funding source at the time of the inspection and there was evidence of the disclosure of billing information.
Client #10 was admitted on 03/16/17 and was an active client at the time of the inspection. The record documented a family session on 05/08/17, but did not contain a consent to release information form to the involved family member. Additionally, the consent to release information form to the funding source, signed and dated on 03/16/17, did not contain an expiration date or a condition of expiration.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 6/27/17 Client #9 completed a consent form for the funding source.
Client # 10 was unable complete a corrected consent form to the funding source because he was discharged on 6/21/17.
A record-keeping training to include a review of confidentiality standards will be facilitated on July 25, 2017 to ensure that all staff adhere to confidentiality standards per DOH Policy 709.28 (c).
All Release of Information Forms will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) for three (3) months to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible: Compliance Director, Division Director, Program Director.
Timeframe for Completion: July 25, 2017
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709.30 (1) 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.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on a review of ten client records, client record #'s 1, 2, 3, 4, 5, and 7 lacked documentation verifying written acknowledgement by clients that they had been notified of each of their client rights.
Client #1 was admitted on 04/10/17 and was discharged on 05/18/17.
Client #2 was admitted on 12/08/16 and was discharged on 01/19/17.
Client #3 was admitted on 05/24/17 and was an active client at the time of inspection.
Client #4 was admitted on 05/25/17 and was an active client at the time of inspection.
Client #5 was admitted on 05/26/17 and was an active client at the time of inspection.
Client #7 was admitted on 11/30/16 and was discharged on 01/18/17.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 7/19/17 we revised the intake package to ensure that all Client Rights Forms are congruent.Client's #3 and #4 signed the revised forms and Client #5 was unable to sign the revised form because they were discharged on 7/13/17.
A record-keeping training to include a review of client rights standards will be facilitated on July 25, 2017 to ensure that all staff adhere to Client Rights Policy per DOH Standard 709.30 (1)
Client Charts will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) for three (3) months to ensure program compliance of Standard 709.30 (1).
Persons Responsible: Compliance Director, Division Director, Program Director.
Timeframe for Completion: July 25, 2017
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709.53(a) LICENSURE Complete Client Record
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:
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Observations
Based on a review of client records, the facility failed to provide a complete client record in client records #'s 1, 2, 3, 4, 5, 6, 7, 8, and 9.
Client #1 was admitted on 04/10/17 and was discharged on 05/18/17. The client record did not contain verification that work done by the client at the project is an integral part of the treatment and rehabilitation plan as of the date of the inspection.
Client #2 was admitted on 12/08/16 and was discharged on 01/19/17. The client record did not contain verification that work done by the client at the project is an integral part of the treatment and rehabilitation plan as of the date of the inspection.
Client #3 was admitted on 05/24/17 and was an active client at the time of inspection. The client record did not contain verification that work done by the client at the project is an integral part of the treatment and rehabilitation plan as of the date of the inspection.
Client #4 was admitted on 05/25/17 and was an active client at the time of inspection. The client record did not contain verification that work done by the client at the project is an integral part of the treatment and rehabilitation plan as of the date of the inspection.
Client #5 was admitted on 05/26/17 and was an active client at the time of inspection. The client record did not contain verification that work done by the client at the project is an integral part of the treatment and rehabilitation plan as of the date of the inspection.
Client #6 was admitted on 07/06/16 and was discharged on 09/02/16. The client record did not contain verification that work done by the client at the project is an integral part of the treatment and rehabilitation plan or follow-up information as of the date of the inspection.
Client #7 was admitted on 11/30/16 and was discharged on 01/18/17. The client record did not contain verification that work done by the client at the project is an integral part of the treatment and rehabilitation plan or follow-up information as of the date of the inspection.
Client #8 was admitted on 04/30/17 and was discharged on 06/13/17. The client record did not contain verification that work done by the client at the project is an integral part of the treatment and rehabilitation plan or follow-up information as of the date of the inspection.
Client #9 was admitted on 05/08/17 and was an active client at the time of inspection. The client record did not contain verification that work done by the client at the project is an integral part of the treatment and rehabilitation plan 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
A follow up on Client #7 was verified and completed on 1/21/17. A follow up was verified and completed on Client #8 on 6/16/17. a verification of the follow up was put in the Follow Up Log.
A record-keeping training to include a review of work therapy on treatment plans and follow up will be facilitated on July 25, 2017 to ensure that all staff adhere to Standard 709.53(a) Complete Client Record.
All record of services and client follow up will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) to ensure compliance of the standard.
Persons Responsible: Compliance Director, Division Director, Program Director.
Timeframe for Completion: July 25, 2017
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