INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 15, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gaudenzia, Inc. Broad Street 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(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 five personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that three employees received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #6 was hired as a support staff on October 5, 2020, and was still in this position at the time of the inspection. Employee # 6 was due to have the communicable disease trainings no later than October 5, 2022. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee # 7 was hired as a support staff on February 16, 2021, and was still in this position at the time of the inspection. Employee #7 was due to have the communicable disease trainings no later than February 16, 2023. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee # 8 was hired as a support staff on August 16, 2021, and was still in this position at the time of the inspection. Employee #8 was due to have the communicable disease trainings no later than August 16, 2023. There was no documentation in the personnel file 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 process.
This is a repeat citation from the June 22, 2023, annual licensing inspection.
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Plan of Correction
Program Director will ensure 3 employees shall be enrolled into required trainings by COB 6/10/24. To prevent reoccurrence, Program Director will utilize tracking tool with Admin. Asst. to monitor training status of all employees on a monthly basis. |
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, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Cameras were located in group rooms where counseling sessions were held.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Gaudenzia has been granted a DDAP exception waiver to 705.4 (3) allowing video-only recording strictly for safety and security purposes in the common areas of the program, including areas which may be used for group sessions. This exception waiver was granted as of 6/18/24.
Gaudenzia is adding language to our consent forms to obtain informed consent from all clients to allow video-only recording strictly for safety and security purposes in the common areas of the program, including areas which may be used for group sessions. This language will be added immediately and will then be reviewed and signed by all current clients prior to their next counseling session.
In the interim, the program will disable any camera which is positioned in such a way as to capture video of any counseling session. These cameras will be enabled once all clients have signed the consents.
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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on one of two applicable client records reviewed, the facility failed to follow their policy to notify the emergency contact within 12 hours when a client leaves against medical advice.
Client # 7 was admitted on April 12, 2024, and was discharged on May 1, 2024. There was no documentation of the emergency contact being notified of the client leaving against medical advice in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will review all Discharges with Clinical Supervisor all staff's ability to navigate our EHR to ensure that anyone leaving against medical advice can have their emergency contact notified in real time and definitely within the 12 ho0urs the regulation requires. To prevent reoccurrence, Joint supervision will be held with Clinical Supervisor and Care Coordinator on a bi weekly basis specifically to review all discharges ensuring all emergency contacts and proper follow up on discharges are occurring as per regulations. This will begin on June 10, 2024. Director will begin immediate retraining of all staff on discharge policies and requirements. |
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 one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the specific information disclosed.
Client # 2 was admitted on April 24, 2024, and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated April 24, 2024, to a lab and pharmacy did not provide the specific information that was to be disclosed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will have Director of Nursing review regulations regarding Confidentiality consent forms with intake Nurse to ensure forms are being done in proper manner. To prevent reoccurrence, Chart audits will be conducted on monthly basis focusing on consent forms. This will be started immediately. Client # 2 no longer in treatment and contact # no longer working. |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the purpose of the disclosure
Client # 2 was admitted on April 24, 2024, and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated April 24, 2024, to a lab and pharmacy did not include the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will meet with Director of Nursing to mandate refresher training for all staff doing consents to labs and pharmacy to make sure they are getting completed in proper manner in accordance with regulations. To prevent reoccurrence, Chart audits will be conducted on monthly basis to ensure consents are completed properly. quarterly updates to be submitted to Program Director by 8/15/24. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on a review of the facility policy and procedure manual, the drug storage area and medications shall be inspected by an assigned nurse or designated trained staff member at least quarterly. The Medication and Drug Storage Inspection form shall be completed quarterly by the individual conducting the inspection and by the nurse manager or program director who accompanies him/her during the inspection. The facility was not documenting an inspection of the drug area and medications at least quarterly.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will meet DON to discuss recording of inventory as required in regulation. To prevent reoccurrence, Program Director will meet DON quarterly to visibly review inventory sheets and storage areas starting today 6-11-24 |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on two of six applicable client records reviewed, the facility failed to provide a psychosocial evaluation in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicated a psychosocial evaluation be completed within five days of admission and include a narrative psychosocial assessment.
Client # 4 was admitted on April 26, 2024, and was still active at the time of the inspection. The biopsychosocial evaluation did not include a narrative psychosocial assessment required by the facility policy and procedure manual.
Client # 5 was admitted on January 23, 2024, and was discharged February 21, 2024. The biopsychosocial evaluation did not include a narrative psychosocial assessment required by the facility policy and procedure manual.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will review all admissions within 3 days of admission to ensure clinical staff are completing Biopsychosocial in accordance to our policies. To prevent reoccurrence, Program and Clinical supervisor will be responsible for properly completing Biopsychosocial and assessment narrative this will start immediately. |
709.53(a)(8) LICENSURE Case Consultation Notes
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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document case consultations within fifteen days of admission, per facility policy, in six out of six applicable records reviewed.
Client # 1 was admitted on April 12, 2024, and was still active at the time of the inspection. A case consultation was due to occur no later than April 27, 2024. There was no documentation that one occurred.
Client # 2 was admitted on April 24, 2024, and was still active at the time of the inspection. A case consultation was due to occur no later than May 9, 2024. There was no documentation that one occurred.
Client # 3 was admitted on April 1, 2024, and was still active at the time of the inspection. A case consultation was due to occur no later than April 16, 2024. There was no documentation that one occurred.
Client # 4 was admitted on April 26, 2024, and was still active at the time of the inspection. A case consultation was due to occur no later than May 11, 2024. There was no documentation that one occurred.
Client # 5 was admitted on January 23, 2024, and was discharged on February 21, 2024. A case consultation was due to occur no later than February 8, 2024. There was no documentation that one occurred. here was no case consultation documented in the client record.
Client # 7 was admitted on April 12, 2024, and was discharged on May 1, 2024. A case consultation was due to occur no later than April 27, 2024. There was no documentation that one occurred.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will make Clinical Supervisor reinstitute Weekly Case Consultations with clinical staff starting June 12, 2024. to ensure all members have a Case Consultation before their first 15 days in our program as per our policy. Program Director will be responsible for following to make sure plan is implemented. |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based on one of three applicable client records reviewed, the facility failed to provide a discharge summary in accordance with the facility policy and procedure manual. The policy and procedure manual indicates a discharge summary be completed within 7 days of discharge.
Client # 7 was admitted on April 12, 2024, and was discharged on May 1, 2024. A discharge summary was due to be completed no later than April 19, 2024, however, there was no documentation that one was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will meet today with Care Coordinator to review all members who were discharged the prior month to review that each member had emergency contact notified and discharge summary was completed with timeframe of our policy. This will begin on June 11, 2024. Program Director will be responsible for immediate implementation and monitoring of this POC to prevent reoccurrence. |