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 October 30, 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 Inc. 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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705.10 (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, the facility failed to ensure that all fire extinguishers are inspected and approved annually as evidenced by the fire extinguisher in the office labeled "Nurse" that was tagged with an inspection date of August 2019.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
On 10/30/20 the Fire extinguisher maintenance Company, Kint, was contacted and requested to service fire extinguisher in the Nurse's office. On 10/30/20, the Fire extinguisher in the Nurse's office was inspected and recharged and updated. The Program Director will inspect all fire extinguishers monthly. This inspection will be documented in the monthly safety report. In addition to the Program Director, the Regional Quality Assurance Manager will inspect all Fire extinguishers quarterly and will document this in a Quarterly CQI report. Any Fire extinguishers found to be inoperable will be addressed immediately with a work order and repaired/ replaced within 48 hours. The compliance department will conduct annual reviews to ensure continued implementation of all action items on the correction action plan. |
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 a review of seven client records, the facility failed to ensure that all consents contained the purpose of disclosure in two client records.
Client#3 was admitted on September 7, 2020 and was still active at the time of the inspection. All consent to release forms within client#3 record are missing purpose of disclosure.
Client#4 was admitted on September 14, 2020 and was still active at the time of the inspection. Consent to release forms dated September 15, 2020 to funding sources and a county agency failed to include purpose of disclosure.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Program Director will meet with client #3 and Client #4 to ensure that the purpose of disclosures are included in the consents. The Program Director will ensure that all future client charts contain all required client consent forms including purpose of disclosure. The Program Director facilitated a training on 10/30/20 and will conduct ongoing trainings as needed to ensure all staff members understand this requirement. The Program Director will ensure compliance in these areas through monthly internal chart audits. In addition, the Regional Quality Assurance Manager will conduct quarterly audits to ensure compliance; this audit will be documented in the quarterly CQI report. The compliance department will conduct annual reviews to ensure continued implementation of all action items on the correction action plan. |
709.28 (c) (5) 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:
(5) Dated signature of witness.
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Observations
Based on a review of seven client records, the facility failed to ensure that all consents contained a dated signature of witness within six client records.
Client#1 was admitted on April 6, 2020 and was still active at the time of inspection. All consent to release forms dated April 7, 2020 within the client ' s record failed to include a dated signature of witness.
Client #2 was admitted on March 25, 2020 and was still active at the time of inspection. Three consents dated October 7, 2020 to an outside agency and one consent dated June 6, 2020 to a government agency failed to include a dated signature of witness.
Client #4 was admitted on September 14, 2020 and was still active at the time of inspection. A consent to release form to an employer dated October 12, 2020 and October 5, 2020 failed to include a dated signature of witness.
Client #5 was admitted on January 29, 2020 and discharged on April 29, 2020. A consent to release form was dated on January 27, 2020 to a government agency the failed to include a dated signature of witness.
Client #6 was admitted on March 30, 2020 and was discharged on April 8, 2020. All consent to release forms dated March 30, 2020 within the client record failed to include a dated signature of witness.
Client #7 was admitted on February 20, 2020 and was discharged on September 9, 2020. All consent to release forms dated February 21, 2020 within the client record failed to include a dated signature of witness.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Program Director will meet with Clients #1 #2 #4 to re-sign all releases which were missing signatures. The Program Director will ensure that in the future all releases contain all required signatures. The Program Director facilitated a training on 10/30/20 and will conduct ongoing trainings as needed to ensure all staff members understand this requirement. The Program Director will ensure compliance in these areas through monthly internal chart audits that will be documented in a monthly report. In addition, the Regional Quality Assurance Manager will conduct quarterly audits to ensure compliance; this audit will be documented in the quarterly CQI report. The compliance department will conduct annual reviews to ensure continued implementation of all action items on the correction action plan. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of seven client records and discussion with Facility Director, the facility failed to provide documentation of physical examination in all seven client records.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Program Director will ensure that documented physical examinations occur within the required timeframe. On 11/11/20, the Program Director Contacted Hamilton health Center, Beacon Health Clinic, and additional resources to ensure clients have multiple options and receive required physical examinations in a timely manner. A staff member will meet with the client upon admission in order to facilitate scheduling of these appointments in a timely manner. The Program Director will conduct monthly audits to ensure compliance; these audits will be documented on a monthly audit report. In addition, the Regional Quality Assurance Manager will conduct quarterly audits to ensure compliance; this audit will be documented in the quarterly CQI report. The compliance department will conduct annual reviews to ensure continued implementation of all action items on the correction action plan. |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to provide documentation of follow up information in client records #5, #6 and #7.
Client #5 was admitted on January 29, 2020 and was discharged on April 29, 2020.
Client #6 was admitted on March 30, 2020 and was discharged on April 8, 2020.
Client #7 was admitted on February 20, 2020 and was discharged on September 9, 2020.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
A complete client record will be maintained for all individuals, which includes follow-up information for all discharged clients. All clinical staff will be trained by the Facility Director in an in-service training on 11/19/20 regarding these requirements and the use of the newly developed /Follow-Up document in the electronic health record. This electronic form will replace our previous system of documenting this in a paper log binder. The Clinical Supervisor will conduct at least weekly audits of charts in order to ensure compliance. The Quality Assurance department will conduct at least quarterly reviews of the program in order to ensure compliance. The findings of these audits will be reviewed in regular CQI meetings following the audits. The Compliance department will conduct at least annual reviews to ensure compliance with corrective action plans. |
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of seven client records, the facility failed to ensure that all work done by the client at the project is an integral part of his treatment and rehabilitation plan in all seven client records.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Program Director will ensure that all daily chores conducted by client is therapeutic in nature and included in all client treatment plans, noting that these chores teach life skills, responsibility, social interaction, and have other therapeutic purposes. The Program Director will ensure treatment plans include information relative to the client's involvement with the project, specifically, work done by clients, and will ensure compliance with this through monthly client chart audits and documentation of audit in a monthly audit report. In addition, the Regional Quality Assurance Manager will conduct quarterly audits to ensure compliance; this audit will be documented in the quarterly CQI report. The compliance department will conduct annual reviews to ensure continued implementation of all action items on the correction action plan. |