INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the June 21-23, 2017 licensure renewal inspection. The follow-up inspection was conducted on October 2, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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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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 October 2, 2017 at approximately 10:00 A.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 bathrooms on the third floor and four shower stalls on the fourth floor. Additionally, tiles were missing and plaster was dented in a bathroom stall on the third floor.
*The plan of correction from the 06/23/2017 annual licensing inspection, submitted and approved on 07/19/2017, stated that the corrective action plan would be completed by 07/14/2017.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On October 3, 2017 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 to have all of the shower's power washed and cleaned on a monthly basis.
The missing tiles and the dented plaster are scheduled to be repaired on October 31, 2017.
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: October 31, 2017 |
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 four client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in one client record. Additionally, consent to release information forms in three client records were missing required components.
Client #1 was admitted on 7/31/17 and discharged on 9/7/17. The record contained a consent to release information form to the funding source, signed on 7/31/17, which did not include the purpose for the disclosure or the specific items to be disclosed. Additionally, the record contained two consent to release information forms to an outside agency, signed on 8/18/17, which did not include witness signatures.
Client #2 was admitted on 9/2/17 and was an active client at the time of 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. Additionally, the record contained a consent to release information form, signed by the client on 9/1/17, which did not indicate the person, agency, or organization to whom the disclosure would be made, the purpose for the disclosure, or the specific information to be disclosed.
Client #3 was admitted on 8/11/17 and was an active client at the time of the inspection. The record contained a consent to release information form to the funding source, signed by the client on 8/11/17, which did not include the purpose for the disclosure or the specific information to be released, and was dated by the witness 8/11/18. The record also contained a consent to release information form to a personal contact, signed by the witness on 8/17/17, which did not contain a client signature.
*The plan of correction from the 06/23/2017 annual licensing inspection, submitted and approved on 07/19/2017, stated that the corrective action plan would be completed by 07/25/2017.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #1 completed a consent form for the funding source to include the purpose of the disclosure and specific items to be disclosed and included a witness signature.
Client #2 completed a consent form for the funding source to include the purpose of the disclosure and specific items to be disclosed and included who the disclosure was to be made.
Client #3 was discharged at the time of the plan of correction.
A record-keeping retraining to include a review of confidentiality standards will be facilitated on November 13, 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: November 13, 2017 |
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 three applicable client records, each client record lacked documentation verifying written acknowledgement by clients that they had been notified of each of their client rights.
Client #1 was admitted on 7/31/17 and was discharged on 9/7/17.
Client #2 was admitted on 9/2/17and was an active client at the time of inspection.
Client #3 was admitted on 08/11/17 and was an active client at the time of inspection.
*The plan of correction from the 06/23/2017 annual licensing inspection, submitted and approved on 07/19/2017, stated that the corrective action plan would be completed by 07/25/2017.
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 #1 was discharged at the time of the DDAP POC and was unable to sign the revised form.
Client #2 was discharged at the time of the DDAP POC and was unable to sign the revised form.
Client #3 was discharged at the time of the DDAP POC and was unable to sign the revised form.
A record-keeping retraining to include a review of client rights standards will be facilitated on November 13, 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: November 13, 2017 |
709.51(b)(4) LICENSURE Consent to treatment
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on a review of two client records, the facility failed to ensure that client record # 2 contained documentation of client signed consent to treatment.
Client #2 was admitted on 9/2/17 and was an active client at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #2 was discharged at the time of the DDAP POC and was unable to sign the revised consent to treatment form.
A record-keeping retraining to include a review of the revised Consent to Treatment Form will be facilitated on November 13, 2017 to ensure that all staff adhere to Complete Client Record DOH Standard 709.53 (a)
Client Charts will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) for three (3) months to ensure program compliance of Standard 709.5 (a).
Persons Responsible: Compliance Director, Division Director, Program Director.
Timeframe for Completion: November 13, 2017 |
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 four client records, the facility failed to provide a complete client record in client records #'s 1, 2, and 3.
Client #1 was admitted on 7/31/17 and was discharged on 9/7/17. 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 9/2/17 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 #3 was admitted on 8/11/17 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 or a record of services as of the date of the inspection.
*The plan of correction from the 06/23/2017 annual licensing inspection, submitted and approved on 07/21/2017, stated that the corrective action plan would be completed by 07/25/2017.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clients #1, #2, #3 were discharged prior to the DDAP POC.
A record-keeping training to include a review of work therapy on treatment plans and follow up will be facilitated on November 13, 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: November 13, 2017 |