INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 18-19, 2018, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Common Ground 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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709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of facility records conducted during the on-site inspection, the facility failed to obtain informed and voluntary consent for the disclosure of information contained in 1 of 13 client records reviewed.
There were six consent to release information forms signed by Client #5 and a staff person on 12/08/2017, that did not have the name of the person, agency or organization to whom the disclosures were to be made.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
The Program Director conducted a training with all clinical and nursing staff on July 25th 2018 on how to properly document and review with residents their consents to release information to outside entities. The RN Supervisor will be responsible for auditing all new intake charts within the first 2 days of admission to treatment to ensure all release are fully completed and contain all necessary information and signatures from the residents and witnessing staff. The RN supervisor and Program Supervisor will be responsible for discarding of any and all incomplete consent forms. Nursing staff and clinical staff will be responsible for making sure consent forms are y completed immediately in the event faulty consent forms are identified in a client chart. The Program Director will be responsible for sending new releases to client #5 to be signed and dated and returned to the facility. |
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 facility records conducted during the on-site inspection, the facility failed to obtain written acknowledgement from clients that they were notified of their rights in 13 of 13 client records reviewed.
The documents given to the clients listing the rights of the clients do not include the clients' right to appeal a decision to limit their access to their records, and the clients' right to request correction of inaccurate, irrelevant, outdated or incomplete information in their records.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
The Program Director will be responsible for adding to the resident rights under section three in the client orientation (pg 17.) a client's right to appeal a decision to limit their access to their records, and the clients' right to request correction of inaccurate, irrelevant, outdated or incomplete information in their records. The Program Director will also will be responsible for reviewing this updated information with all currents residents in the facility. |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on a review of facility records conducted during the on-site inspection, the facility failed to ensure that it properly screened all of its clients during the intake process.
Client # 8 was admitted for narcotic detox on 02/19/2018, and was administered a narcotic agent 02/19/2018, but the facility had no documentation of acceptable identification for the client.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Nursing staff are responsible for ensuring all residents receiving medication have an acceptable picture identification with their MAR. The nursing staff are also responsible for ensuring all detox residents receiving suboxone maintenance have acceptable picture identification prior to receiving their first dose. The RN supervisor will be responsible for monitoring the MAR book daily to make sure all residents receiving medication have an appropriate photo identification. |
715.14(d) LICENSURE Urine testing
(d) A narcotic treatment program shall ensure that a laboratory that performs the testing required under this section shall be in compliance with applicable Federal requirements, specifically the Clinical Laboratory Improvement Amendments of 1998 (42 U.S.C.A. §§ 201 note, 263 and 263a notes), and State requirements, specifically the Pennsylvania Clinical Laboratory Act (35 P.S. §§ 2151-2165) and Chapter 5 (relating to clinical laboratories).
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Observations
Based on a review of facility records conducted during the on-site inspection, and based on staff interviews conducted during the on-site inspection, the facility failed to ensure that all of its urine screens were performed by a laboratory that was in compliance with the Clinical Laboratory Improvement Amendments of 1998 (CLIA).
The initial urine screen for Client #8 dated 02/19/2018, was performed by the facility, but the facility is not a CLIA approved facility.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
The RN supervisor will be responsible for making sure all urine screenings collected by medical staff are sent to Quest diagnostics for analysis. The RN supervisor and Program Director have submitted all information for the facility to receive a CLIA waiver. It is anticipated no later than November 1st 2018 the CLIA waiver will be received. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of facility records conducted during the on-site inspection, the facility failed to document the frequency of services on treatment plans in three of seven client records reviewed.
Client #3 was admitted for treatment on 12/12/2017, and discharged on 01/09/2018. The client's individualized treatment plan dated 12/16/2017, and treatment plan update dated 01/01/2018, did not give the frequency of individual counseling or group counseling.
Client #6 was admitted for treatment on 05/23/2018, and was an active client at the time of the on-site inspection. The client's individualized treatment plan dated 05/27/2018, and treatment plan update dated 06/19/2018, did not give the frequency of individual counseling or group counseling.
Client #7 was admitted for treatment on 05/29/2018, and was an active client at the time of the on-site inspection. The client's individualized treatment plan dated 05/30/2018, did not give the frequency of individual counseling or group counseling.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
The Program Supervisor will meet with all clinicians by 7/20/18 to discuss and review the frequency of services for treatment planning. In addition, the electronic treatment plan form is currently undergoing revisions to provide space to specify both type and frequency of interventions as well as prompts to remind the clinician to address this area. These revisions will be completed and fully implemented by 7/31/18. Resident #3, Resident #6, and Resdident #7 have all been discharged since the completion of this POC. |