INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on November 16-20, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, Gaudenzia Erie Inc./Community 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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705.7 (b) (6) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(6) Store all food items off the floor.
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Observations
Based on a physical site inspection on November 18, 2020, the facility failed to store all food items off the floor. Bottles of water were observed on the floor of the basement.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Staff will be trained in the proper storage of food items by the Program Director. All food items will be stored on shelves keeping the items off the floor.
House managers will ensure this during their nightly rounds of the building with the Program Director overseeing that it is completed.
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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 the review of client records on November 16-20, 2020, the facility failed to document a completed informed and voluntary consent in client record #'s 1 and 6.
Client #1 was admitted on May 29, 2020 and discharged on September 18, 2020. A consent to release information form dated June 3, 2020 had a "?" for whom the information could be disclosed to.
Client #6 was admitted on August 10, 2020 and was still active at the time of the inspection. A consent to release information form dated August 9, 2020 had "need to obtain" for whom the information could be disclosed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Training will be completed with all staff regarding the correct way to complete a Consent to Release Information form. The Program Director will facilitate this training, stressing the importance of filling out the Consent to Release of Information in its entirety before any signatures are obtained
The Program Director will review the releases while completing weekly chart audits and if any errors are found, the Program Director will address it with the staff member, new releases will be completed, and the old releases will be voided.
The Quality Assurance Manager will review releases during quarterly chart audits and report findings to the Program Director who will ensure that this is addressed as described above.
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