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 October 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 West Shore 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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Observations
Based on a review of client records, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in client record #'s 1, 3 and 4.
Client #1 was admitted on August 14, 2020 and was an active client as of the date of the inspection. Consent to release forms were signed and dated on August 10, 2020 to the funding source and County agency that allowed for the release of case consults, mental health records, discharge summary, progress notes, and medication records.
Client #3 was admitted on August 3, 2020 and was an active client as of the date of the inspection. Consent to release forms were signed and dated on June 8, 2020 to the funding sources, county agencies that allowed for the release of case consults, mental health records, discharge summary, progress notes, assessments and medication records.
Client #4 was admitted on August 14, 2020 and was an active client as of the date of the inspection. A consent to release form was signed and dated on August 20, 2020 to the funding source that allowed for the release of case consults, mental health records, discharge summary, progress notes, and medication records.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
An In-Service Training for the Clinical Staff has been scheduled for 11/20/2020 to review 4 PA. Code 255.5. The In-Service will include reviewing agencies and the allowable information per agency according to 4 PA. Code 255.5 The In-Service will be completed by the Division Director and Clinical Supervisor.
The In-Service training will be documented by a sign-in sheet and agenda.
Ongoing compliance will be completed by the Clinical Supervisor during monthly chart audits. The Clinical Supervisor will audit a minimum of 5 records, per counselor, each month and document using internal audit checklist. Any concerns pertaining to 4 Pa. Code 255.5 will be addressed in a documented supervision meeting. This will begin for the month of November 2020.
The Division Director will audit 5 open chart records per month to ensure limits of 4 Pa. Code 255.5 is being adhered to and document the audits on the internal checklist. |