INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 2, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Kindred 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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705.11 (2) (iv) LICENSURE Child care.
705.11. Child care.
(2) Interior space. The residential facility shall:
(iv) Secure all hazardous and poisonous substances and materials with safety latches or locks.
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Observations
Based on the physical plant inspections, the facility failed to secure all hazardous and poisonous substances and materials with safety latches or locks.
An open bottle of detergent was found under an unlocked kitchen sink in the daycare building.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of June 2, 2021, all hazardous materials were removed and placed in a secure, restricted area. Staff will monitor hazards in hourly safety checks throughout the program that are documented on the run sheet. In addition the Quality Assurance Department conducts quarterly reviews, and the Compliance department conducts reviews of corrective action plans to ensure implementation. |
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 client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in three of seven client records reviewed.
Client #1 was admitted on December 8, 2020 and was an active client at the time of the inspection. There was documentation of facsimile communication between staff and a county assistance office on April 9, 2021; however, there was no documentation of informed and voluntary consent from the client.
Client #3 was admitted on October 23, 2020 and was an active client at the time of the inspection. There was documentation of communication between staff and a county assistance office on November 10, 2020; however, there was no documentation of informed and voluntary consent from the client. Additionally, there was documentation of communication between staff and a public defender ' s office on November 30, 2020; however, there was no documentation of informed and voluntary consent from the client until April 21, 2021.
Client #5 was admitted on September 11, 2020 and was discharged on February 26, 2021. A release of information form for the funding source was not documented in the client record.
These findings were reviewed with project staff during the licensing process.
This is a repeat citation from last year's licensure renewal inspection.
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Plan of Correction
The Program Director will conduct an in-service meeting with the clinical team by June 25, 2021 regarding the limitations of confidentiality when completing the disclosure consents with an emphasis on appropriate release to the county assistance office. Moving forward, all client documentation, including the disclosure consents will be reviewed by the Program Director or designee weekly to ensure consents are appropriately completed and do not exceed the limits established by 4 Pa. Code 255.5. In addition the Quality Assurance Department conducts quarterly reviews, and the Compliance department conducts reviews of corrective action plans to ensure implementation. |
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, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the name of the person, agency or organization to whom the disclosure is to be made in two of seven client records reviewed.
Client #3 was admitted on October 23, 2020 and was an active client at the time of the inspection. A release of information form, signed by the client on October 23, 2020, did not specify the name of the person, agency or organization.
Client #5 was admitted on September 11, 2020 and was discharged on February 26, 2021. A release of information form, signed by the client on September 11, 2020, did not specify the name of the person, agency or organization.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Program Director will conduct an in-service meeting with the clinical team by June 25, 2021 regarding the limitations of confidentiality when completing the disclosure consents with an emphasis on including documentation of the name of the person, agency or organization. Moving forward, all client documentation, including the disclosure consents will be reviewed by the Program Director or designee weekly to ensure consents are appropriately completed and do not exceed the limits established by 4 Pa. Code 255.5. In addition the Quality Assurance Department conducts quarterly reviews, and the Compliance department conducts reviews of corrective action plans to ensure implementation.
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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 the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the purpose of disclosure in one of seven client records reviewed.
Client #3 was admitted on October 23, 2020 and was an active client at the time of the inspection. A release of information form for a primary care physician, signed by the client on October 23, 2020, did not document the purpose of disclosure.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Program Director will conduct an in-service meeting with the clinical team by June 25, 2021 regarding the limitations of confidentiality when completing the disclosure consents with an emphasis on documenting the purpose of the disclosure. Moving forward, all client documentation, including the disclosure consents will be reviewed by the Program Director or designee weekly to ensure consents are appropriately completed and do not exceed the limits established by 4 Pa. Code 255.5. In addition the Quality Assurance Department conducts quarterly reviews, and the Compliance department conducts reviews of corrective action plans to ensure implementation. |
709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the date, event or condition upon which the consent will expire in one of seven client records reviewed.
Client #5 was admitted on September 11, 2020 and was discharged on February 26, 2021. A release of information form for a child welfare agency, signed by the client on November 18, 2020, did not document the date, event or condition upon which the consent will expire.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Program Director will conduct an in-service meeting with the clinical team by June 25, 2021 regarding the limitations of confidentiality when completing the disclosure consents with an emphasis on appropriate release to the county assistance office. Moving forward, all client documentation, including the disclosure consents will be reviewed by the Program Director or designee weekly to ensure consents are appropriately completed and do not exceed the limits established by 4 Pa. Code 255.5. In addition the Quality Assurance Department conducts quarterly reviews, and the Compliance department conducts reviews of corrective action plans to ensure implementation. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on the review of the unusual incidents log, the project failed to file a written unusual incident report with the Department within 3 business days following an unusual incident involving events at the facility requiring the presence of police, fire or ambulance personnel.
On November 7, 2020, there were two separate unusual incidents requiring the presence of ambulance personnel. There was no documentation that these unusual incidents were ever reported to the Department.
On November 24, 2020, there was an unusual incident requiring the presence of ambulance personnel. There was no documentation that this unusual incident was ever reported to the Department.
On February 7, 2021, there was an unusual incident requiring the presence of ambulance personnel. There was no documentation that this unusual incident was ever reported to the Department.
On February 26, 2021, there was an unusual incident requiring the presence of ambulance personnel. There was no documentation that this unusual incident was ever reported to the Department.
These findings were reviewed with project staff during the licensing process.
This is a repeat citation from last year's licensure renewal inspection.
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Plan of Correction
As of June 3, 2021, all incidents will be reviewed during daily morning staff communication meetings, including timely submission of reports. The Program Director/Clinical Supervisor will ensure that all reportable incidents are completed and signed within 24 hours and submitted to DDAP within the regulatory timeframe. In addition, all incidents will be uploaded to Gaudenzia's Internal Incident Portal System.
All program staff are required to complete an Incident Management Refresher Course using the organization's online training system during their orientation period. The Program Director/ Clinical Supervisor will ensure all current staff have completed, or will complete this training by July 15, 2021. In addition, the Quality Assurance Department will conduct quarterly reviews and the Compliance Department will conduct reviews of corrective action plans to ensure implementation.
As of June 30, 2021, incidents from November 7, 2020, November 24, 2020, February 7, 2021 and February 26, 2021 will be submitted to DDAP.
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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 the review of client records, the project failed to ensure that counseling services are provided according to the individual treatment and rehabilitation plan in three of seven client records reviewed.
Client #3 was admitted on October 23, 2020 and was an active client at the time of the inspection. A comprehensive treatment and rehabilitation plan completed on October 23, 2020, indicated that the client was to receive one individual counseling session per week; however, there was no documentation that the client receive an individual counseling session the weeks of October 25, 2020 through October 31, 2020 and December 20, 2021 through December 26, 2021.
Client #4 was admitted on November 24, 2020 and was discharged on April 7, 2021. A comprehensive treatment and rehabilitation plan completed on November 24, 2020, indicated that the client was to receive one individual counseling session per week; however, there was no documentation that the client receive an individual counseling session the week of November 29, 2020 through December 5, 2020.
Client #5 was admitted on September 11, 2020 and was discharged on February 26, 2021. A comprehensive treatment and rehabilitation plan completed on September 11, 2020, indicated that the client was to receive one individual counseling session per week; however, there was no documentation that the client receive an individual counseling session the weeks of October 25, 2020 through October 31, 2020 and November 29, 2020 through December 5, 2020.
These findings were reviewed with project staff during the licensing process.
This is a repeat citation from last year's licensure renewal inspection.
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Plan of Correction
Effective June 3, 2021, the Program Director conducts a weekly clinical supervision with counselors in which all client counseling sessions are reviewed and discussed. Clinical documentation findings will be reported to the Clinical Supervisor and/or Division Director for follow up directly with clinicians. Findings will also be reported and documented in the monthly Eastern Region CQI Meetings. In addition the Quality Assurance Department conducts quarterly reviews, and the Compliance department conducts reviews of corrective action plans to ensure implementation.
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