INITIAL COMMENTS
|
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. - Crossroads 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:
|
Plan of Correction
|
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
|
Observations
Based on a physical site inspection on November 18, 2020, it was observed that the facility failed to ensure privacy so that counseling sessions cannot be seen outside the counseling room as the third-floor back corner office did not have window coverings.
The findings were reviewed with facility staff during the licensing process. This is a repeat citation from the August 8-10, 2019 licensing inspection.
|
Plan of Correction
The Program Director will submit a work order to the Operations Manager requesting new window coverings for privacy purposes for the 3rd floor back corner office. Once approved, the window coverings will be purchased and installed by the Operations Manager. The Program Director will complete a monthly walk through of the building to ensure the facility is in compliance with physical regulations. Quality Assurance Manager will monitor for compliance during quarterly site visit |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
|
Observations
Based on a physical site inspection on November 18, 2020, the facility failed to maintain bathrooms in a clean and sanitary manner. Four dirty showers were observed in the second-floor men's bathroom and one dirty shower was observed in the female third floor bathroom.
These findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the August 8-10, 2019 licensing inspectiion.
|
Plan of Correction
Bathrooms are cleaned each morning, this includes the showers. The bathrooms will be checked by the House Manager for cleanliness after they are cleaned every morning and at least once during each shift. If the bathroom is not clean and sanitary, the individual assigned to clean the bathrooms that day will clean the bathroom to be re-inspected by the House Manager. A Restroom Cleaning Sign-Off sheet will be posted in the bathrooms indicating the date, time and who cleaned/inspected the bathroom. Clients will also be reminded during their house meetings that it is their responsibility to ensure the bathroom and shower is clean after they use it. Condition of the bathrooms will be monitored during quarterly site visits conducted by the QA Manager. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
|
Observations
Based on a review of client records on November 16-20, 2020, the facility failed to keep disclosures of client identifying information within the limited established by 4 Pa. Code 255.5 (b) for releases of information in client record #4. The releases of information permitted progress notes to be released.
Client #4 was admitted on October 21, 2020 and discharged on October 26, 2020. The two releases of information dated October 26, 2020 were both to a government agency.
The findings were reviewed with facility staff during the licensing process.
|
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 255.5 regulations regarding information being released to government agencies. The Clinical Supervisor will review the releases while completing weekly chart audits and if any erroneous information is found, the Clinical Supervisor 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. The Electronic Record System has been updated to allow only the items listed under the 255.5 regulations to be released to government agencies. When the staff member identifies the release is going to a government agency they will only be able to select items listed under the 255.5 regulations. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
|
Observations
Based on the review of client records on November 16-20, 2020, the facility failed to document a completed consent to release information form in client #2. The forms did not document if the client as offered a copy of the release of information form.
Client #2 was admitted on June 15, 2020 and discharged on June 22, 2020. Two of the consent forms were to a laboratory and one was to a pharmacy. All consent forms were dated June 15, 2020.
The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Training will be completed will all staff regarding the correct way to complete a Consent to Release Information form. The Program Director will facilitate this training stressing completing all aspects of the release including whether the client would like a copy of the release or not. The Clinical Supervisor will review the releases while completing weekly chart audits, and if any erroneous information is found, the Clinical Supervisor 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 and Clinical Supervisor who will ensure that this is addressed as described above. |
709.32 (c) (2) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(2) Drug storage areas including, but not limited to, the secure storage of controlled substances and other abusable drugs in accordance with State and Federal regulations and program requirements.
|
Observations
Based on a physical site inspection on November 18, 2020, it was observed that drugs used by clients were not secure. A client's medication was observed to be in a medication cup and placed on top of the medication cart in anticipation of the client arriving for his/her medications. The medications were also left unattended. The observation conflicts with the facility's policy and procedures regarding medication administration.
The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
All staff will be trained on the correct procedure for storing and dispensing medication. No medication will be removed from the medication cart prior to the client presenting to receive their medication. Medication will never be left unattended, it will always be placed back into the medication cart and locked once the client has received it. The Nursing Supervisor will ensure the procedure regarding dispensing medication is followed. |