INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 10 - 12, 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, Inc. People With Hope/Short-Term Program 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, 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. 31 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
Plan of Correction:
The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program completion of the annual assessment of staff training needs. The Plan for Assessing Staff Training Needs will be ready for implementation effective Jan. 31st of each year.
The relevant Gaudenzia Policy has been revised to state that, "Program-level training needs assessments are due to the Training department by the end of January of each year. Upon receipt of the program-level annual assessments of staff training needs, the Director of Training and Education, in collaboration with the Project Director, will review the assessments 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 timeframe each year.
The following persons will be responsible to ensure the corrective action is implemented:
Division Director
Program Director
Program Supervisor
Timeframe for Completion: April 30, 2020
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Reports (SRFSR) form, the facility failed to ensure that employee # 5 received the minimum of six hours of HIV/AIDS training within the regulatory timeframe.
Employee #5 was hired as a counselor assistant on October 3, 2017 and was due to have the communicable disease training no later than October 3, 2018. The facility was unable to produce documentation of the completion of the HIV/AIDS training as of the date of the inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Plan of Correction:
Employee #5 will receive the minimum of six hours of HIV/AIDS training on August 8, 2019 at Gaudenzia's Training Institute. The training is scheduled from 9am-1pm.
The Director of Training and Education will be ultimately responsible for ensuring that all staff (to include administrative staff) receive required HIV/AIDS with the 1st year of employment. Training department staff will review all staff files during the orientation process to ensure that this training is completed.
The Program Director will ensure that all new employees receive at least 6 hours of HIV/AIDS training; four hours of TB/STD and other health related topics within the regulatory timeframe per DDAP Policy 704.11 (c)(1).
The following persons will be responsible to ensure the corrective action is implemented:
Director of Training and Education
Division Director
Program Director
Program Supervisor
Timeframe for Completion: August 8, 2019
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705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on a physical plant inspection on June 12, 2019, it was observed that the facility failed to maintain trash dumpsters in a manner to prevent the penetration of insects and rodents. The lids to the dumpsters were observed open with trash protruding out of the top.
The findings were reviewed with facility staff at the time of the inspection.
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Plan of Correction
Plan of Correction:
The facility will maintain trash dumpsters in a manner to prevent the penetration of insects and rodents. The lids to the dumpsters will be monitored per DDAP Policy 705.2 (4)
House Managers who monitor the members taking out trash along with the kitchen staff will ensure that the lids are closed and monitored per the policy.
The following persons will be responsible to ensure the corrective action is implemented:
Division Director
Program Director
Program Supervisor
Food Service Manager
House Managers
Timeframe for Completion: June 13, 2019
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705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection on June 11, 2019, it was observed the facility failed to ensure all fire extinguishers were inspected annually. The fire extinguisher located on the eighth floor to the left of the elevator as one exits the elevator was last inspected in 2017.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Plan of Correction:
The facility will monitor the Fire Extinguishers monthly and inspected annually to ensure that they are in compliance Per DDAP Policy 705.10 (c)(3)
The Program Director signed off on the 8th floor Fire Extinguisher to ensure compliance on 6/14/19. Boardman Fire Extinguisher Company will be here on Monday August 19, 2019 to replace the extinguisher.
The following persons will be responsible to ensure that the fire Extinguishers will be monitored on a monthly basis and will be inspected annually to ensure that they are operable according to the policy:
Program Director
Program Supervisor
House Manager Supervisor
House Managers
Timeframe for Completion: June 14, 2019
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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, 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 10, 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 departments will review the DDAP 705.10 (c) (4) - 705.28 (c) (4) regulations by 7/31/19, 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.
Persons Responsible:
The Director of Training and Education
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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 10-12, 2019.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
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 departments will review the DDAP 705.10 (c) (4) - 705.28 (c) (4) regulations by 7/31/19, 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.
Persons Responsible:
Director of Training and Education
Date of Completion: 7/31/19
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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 the review of seven client records on June 10-12, 2019, the facility failed to document a completed consent to release information in seven records.
Client #1 was admitted on May 2, 2019 and was still active at the time of the inspection. The client did not have any consent to release information forms in his/her record. During an interview with the facility director, acknowledgement was made that there should have been consent to release forms, especially for the funding source, in the client's record.
Client #2 was admitted on April 1, 2019 and was still active at the time of the inspection. The client did not have a consent to release information form to the funding source in his/her record. During an interview with the facility director, acknowledgement was made that there should have been a consent to release form for the funding source in the client's record.
Client #3 was admitted on November 19, 2018 and discharged on February 19, 2019. The client did not have any consent to release information forms in his/her record. During an interview with the facility director, acknowledgement was made that there should have been consent to release forms, especially for the funding source, in the client's record.
Client #4 was admitted on February 5, 2019 and discharged on May 3, 2019. The discharge summary included information that a consultation occurred with another treatment rehabilitation facility regarding the client's aftercare. There was no consent to release information form in the client's record for the other treatment rehabilitation facility.
Client #5 was admitted on April 7, 2019 and discharged on May 30, 2019. The client did not have any consent to release information forms in his/her client record. During an interview with the facility director, acknowledgement was made that there should have been consent to release forms, especially for the funding source, in the client's record.
Client #6 was admitted on December 11, 2018 and discharged on January 17, 2019. The discharge summary included information that a consultation occurred with another treatment rehabilitation facility regarding the client's aftercare. There was no consent to release information form in the client's record for the other treatment rehabilitation facility.
Client #7 was admitted on February 5, 2019 and discharged on March 25, 2019. The client did not have any consent to release information forms in his/her client record. During an interview with the facility director, acknowledgement was made that there should have been consent to release forms, especially for the funding source, in the client's record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
The People With Hope Program will obtain an informed and voluntary consent from the client for the disclosure of specific information disclosed in the charts during admission. We will review all other current open charts and obtain an informed and voluntary consent form for them as needed. This has been in effect since July 17, 2019 and charts will be reviewed on a monthly basis during CQI.
On September 9, 2019 a Record-Keeping training will be facilitated to review the 4 PA Code 255.5 Confidentiality Request to Release Information Form and DOH Policy 709.28 (c)(1).
All Consent to Release Information Forms will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings and to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible:
Division Director
Program Director
Program Supervisor
Timeframe for Completion: September 9, 2019
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709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on the review of seven client records on June 10-12, 2019, the facility failed to keep disclosures of client identifying information with the limits established by 4 Pa. Code 255.5(b) for releases of information in one client record.
Client #4 was admitted on February 5, 2019 and discharged on May 3, 2019. Two consent to release forms were signed and dated on February 26, 2019 to the funding source and the probation officer that allowed for the release of "any pertinent information for funding including treatment progress". The consent to release information forms did not specify information to released within the limits restricted in the code. As an additional point, the consent to the funding source was dated twenty-one days following the client's admission.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
The Gaudenzia People With Hope Program will obtain an informed and voluntary consent from the client for the disclosure of specific information disclosed in the current charts. The consent will be in writing and include, but not limited to specific information disclosed. This has been in effect since July 17, 2019 and charts will be reviewed on a monthly basis during CQI.
On September 9, 2019 a Record-Keeping training will be facilitated to review the Confidentiality Request to Release Information Form and DOH Policy 709.28(c)and PA Code 255.5. Projects and Coordinating Bodies: Disclosure of Client-Oriented Information.
All Consent to Release Information Forms will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings and to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible:
Division Director
Together House Program Director
Together House Supervisors
Timeframe for Completion: September 9, 2019
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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 10-12, 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 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
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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 10-12, 2019, the facility's client's rights documentation, which is included in the orientation packet, failed to include all the required client rights, including the client's 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
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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 10-12, 2019, the facility's client's rights documentation, which is included in the orientation packet, failed to include all the required client rights, including the client's 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
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715.22(b) LICENSURE Patient grievance procedures
(b) The procedure shall permit aggrieved patients a full and fair opportunity to be heard, to question and confront persons and evidence used against them and to have a fair review of their grievances by the narcotic treatment program director. If the grievance is filed against the narcotic treatment program director, the review of the case shall be conducted by either a multi-representative group of the narcotic treatment program or a subcommittee of the governing body instituted for the express purposes of grievance adjudication.
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Observations
Based on a review of the project's policy and procedure manual, the project's grievance procedure does not address permitting patients a full and fair opportunity to be heard, to question and confront persons and evidence used against them and to have a fair review of their grievances by the narcotic treatment program director.
Based on a review of the project's policy and procedure manual, the project's grievance procedure does not address grievances filed by patients against the narcotic treatment program director.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
715.22(b) LICENSURE
The Continuous Quality Improvement Director has revised the Gaudenzia Client Bill of Rights to accurately reflect the DDAP 715.22 (b)regulations regarding a client's right to inspect their own record and actions they make take in this regard to grievances. 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
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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 seven client records on June 10-12, 2019, the facility failed to document a signed consent to treat authorization from the client prior to starting treatment services.
Client #1 was admitted on May 2, 2019 and was still active at the time of the inspection. The consent to treat form was signed and dated on May 3, 2019. The client's record indicated an individual session occurred on May 2, 2019.
Client #5 was admitted on April 7, 2019 and discharged on May 30, 2019. The consent to treat form was signed and dated on April 11, 2019.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Plan of Correction:
The Gaudenzia Together House PWH Program will document a completed Consent to Treatment in current Open Records.This has been in effect since July 17, 2019 and charts will be reviewed on a monthly basis during CQI.
On September 9, 2019 a Record-Keeping training will be facilitated to adhere by Policy and DOH Policy 709.33.
All of the members who are admitted will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings and to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible:
Division Director
Together House Program Director
Together House Supervisors
Timeframe for Completion: September 9, 2019
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709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of seven client records on June 10 - 12, 2019, the facility failed to document treatment plan updates within the regulatory timeframe in five client records reviewed.
Client #1 was admitted on May 2, 2019 and was still active at the time of the inspection. A comprehensive treatment plan was completed on May 2, 2019 and the next update was due no later than June 2, 2019; however, there was no update documented in the record at the time of the inspection.
Client #2 was admitted on April 1, 2019 and was still active at the time of the inspection. A treatment plan update on completed on May 1, 2019 and the next update was due no later than June 1, 2019; however, there was no update documented in the record at the time of the inspection.
Client #3 was admitted on November 19, 2018 and discharged on February 19, 2019. A treatment plan was completed on January 4, 2019 and the next update was due no later than February 4, 2019; however, there was no updates documented in the record at the time of the inspection.
Client #4 was admitted on February 5, 2019 and discharged on May 3, 2019. A comprehensive treatment plan was completed on February 9, 2019 and the next update was due no later than March 9, 2019; however, the next treatment plan update was completed on April 10, 2019.
Client #7 was admitted on February 5, 2019 and discharged on March 25, 2019. A comprehensive treatment plan was completed on February 5, 2019 and the next update was due no later than March 5, 2019; however, there was no update documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
The Gaudenzia PWH Program will review and update treatment plans within the regulatory guidelines as outlined in 709.52 Treatment and Rehabilitation Services. The long term member updated plan will be every 30 days; short term rehabilitation updated at least every 15 days.
The program supervisor will monitor the active charts weekly and every 30 days during our Continuous Quality Improvement (CQI) meetings
On September 9, 2019 a Record-Keeping training will be facilitated to review the 709.52: Treatment and Rehabilitation services.
All of the members who are discharged will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings and to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible:
Division Director
Together House Program Director
Together House Supervisors
Timeframe for Completion: September 9, 2019
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709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of seven client records on June 10-12, 2019, there was no documentation the clients received counseling services according to their individual comprehensive treatment plan in five charts reviewed.
Client #1 was admitted on May 2, 2019 and was still active at the time of the inspection. The comprehensive treatment plan, dated May 2, 2019, indicated weekly group sessions. The record of service and progress notes indicated the client's first group session was on May 14, 2019 and the last time the client attended group was on May 30, 2019. There was no documentation of group session attendance prior to May 14 or after May 30, 2019.
Client #2 was admitted on April 1, 2019 and was still active at the time of the inspection. The comprehensive treatment plan, dated April 1, 2019, indicated weekly group and individual sessions. The record of service and progress notes indicated the client received no individual sessions between April 30 - May 12, and May 14 - June 2, 2019. The documentation indicated the client received no group sessions between April 18 - May 13, May 15 - May 29 and after May 31, 2019.
Client #3 was admitted on November 19, 2018 and discharged on February 19, 2019. The comprehensive treatment plan, dated January 4, 2019, indicated weekly individual sessions. The record of service and progress notes indicated the client received no individual sessions between January 5 - 13, January 19 - February 5, 2019.
Client #4 was admitted on February 5, 2019 and discharged on May 3, 2019. The comprehensive treatment plan, dated February 9, 2019, indicated weekly group and individual sessions. The record of service and progress notes indicated the client received no individual sessions between February 10 - April 17, and after April 19, 2019. In addition, the chart indicated no group sessions between February 12 - 28, March 9 - 17 and after April 18, 2019.
Client #7 was admitted on February 5, 2019 and discharged on March 25, 2019. The comprehensive treatment plan, dated February 5, 2019, indicated weekly individual and group sessions. The record of service and progress notes indicated the client received one individual session on March 13, 2019. The chart indicated the client's first group session was on March 4, 2019 with no sessions between March 9 - 17, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
The Gaudenzia Together House PWH Program will documentation the clients received counseling services according to their individual comprehensive treatment plan within the regulatory guidelines as outlined in 709.52
Treatment and Rehabilitation Services.
On September 9, 2019 a Record-Keeping training will be facilitated to review the 709.52: Treatment and Rehabilitation services.
All of the members files will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings and to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible:
Division Director
Together House Program Director
Together House Supervisors
Timeframe for Completion: September 9, 2019
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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 seven client records on June 10-12, 2019, the facility failed to provide a complete client record, which is to include discharge summaries, aftercare plans, case consultation notes, follow-up information and documentation of work therapy in seven records.
Client #1 was admitted on May 2, 2019 and was still active at the time of the inspection. The client record did not contain documentation of work therapy.
Client #2 was admitted on April 1, 2019 and was still active at the time of the inspection. The client record did not contain documentation of work therapy.
Client #3 was admitted on November 19, 2018 and discharged on February 19, 2019. The client record did not contain documentation of work therapy and case consultation.
Client #4 was admitted on February 5, 2019 and discharged on May 3, 2019. The client record did not contain documentation of work therapy and case consultation.
Client #5 was admitted on April 7, 2019 and discharged on May 30, 2019. The client record did not contain documentation of work therapy, case consultation, discharge summary, aftercare plan and follow-up information.
Client #6 was admitted on December 11, 2018 and discharged on January 17, 2019. The client record did not contain documentation of work therapy.
Client #7 was admitted on February 5, 2019 and discharged on March 25, 2019. The client record did not contain documentation of work therapy.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
The Gaudenzia Together House PWH Program will provide a complete client record in all Open Charts, which is to include case consults, aftercare plans, discharge summaries, follow-up information and documentation of work therapy. This has been in effect since July 17, 2019 and charts will be reviewed on a monthly basis during CQI.
On September 9, 2019 a Record-Keeping training will be facilitated to review the DOH Policy 709.53 Complete Client Record.
All complete client records will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings and to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible:
Division Director
Together House Program Director
Together House Supervisors
Timeframe for Completion: September 9, 2019
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