INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on July14, 2021 through July 16, 2021 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Guadenzia Inc. - Kindred House was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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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.
3/21/21 - 6:00pm client taken to ER via ambulance for pain
5/15/21 - 1:30pm client taken to ER via ambulance
5/18/21 - 9:20pm fire alarm went off and Fire personnel responded
7/1/21 - 7:35 pm client take to ER via ambulance due to bleeding
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Plan of Correction
As of July 28, 2021, incidents from March 21, 2021 @ 6:00 pm;
May 15, 2021 @ 1:30 pm;
May 18, 2021 @ 9:20 pm and
July 1, 2021 @7:35 pm was submitted to DDAP.
All incidents will be reviewed during 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. period. The Program Director/ Clinical Supervisor will ensure all current staff have completed, or will complete this training by July 31, 2021. In addition, the Quality Assurance Department will conduct quarterly reviews and the Compliance Department will conduct annual reviews of corrective action plans to ensure implementation
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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 a review of four client records on July 15, 2021, the facility failed to document a discharge summary within 7 days after the client's discharge date.
Client #3 was admitted on 6/15/21 and discharged on 6/27/21.
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Plan of Correction
The Program Director will conduct an in-service meeting with the clinical team on July 29, 2021 regarding completing the continuing care transition discharge summary within 72 hours post discharge. Effectively immediately, the Program Director or designee will review all discharged records within 72 hours to ensure that discharge documentation has been appropriately completed. Workflow documents established for this level of care will be reviewed during in-service training.
Additionally, CQI/Compliance Department will conduct quarterly clinical chart audits, including discharged records, ensuring that all discharged documentation has been completed as required.
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