This report is a result of an on-site licensure renewal inspection conducted on April 18, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the 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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Observations
Based on a review of seven client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in four records reviewed.
Client # 4 was admitted on June 26, 2023 and was discharged on October 23, 2023. Per a discussion with the Clinical Supervisor, information such as client diagnosis was disclosed to the funding source, however, the consent to release information form to the funding source signed by the client on June 26, 2023, did not allow for the release of that information.
Client # 5 was admitted on February 1, 2024 and was active at the time of the inspection. Per a discussion with the Clinical Supervisor, information such as client diagnosis was disclosed to the funding source, however, the consent to release information form to the funding source signed by the client on February 1, 2024, did not allow for the release of that information.
Client # 6 was admitted on October 10, 2023 and was discharged on April 17, 2024. The record contained evidence of disclosures to a family member during a family counseling session on April 3, 2024; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
Client # 7 was admitted on September 27, 2023 and was active at the time of the inspection. Per a discussion with the Clinical Supervisor, information such as client diagnosis was disclosed to the funding source, however, the consent to release information form to the funding source signed by the client on September 27, 2023, did not allow for the release of that information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All Clinical Staff will be trained regarding the importance of completing consent forms fully, including a list of all information to be disclosed. The Clinical staff will be reminded that a consent needs to be completed for any family contact/involvement. New Consent forms for all current active clients have been completed on 4/22/2024. The Program Director and Clinical Supervisor will audit charts on a bi-weekly basis. The findings of these audits will be reviewed on an individual basis with clinicians and this review will be documented in a supervision note. Any areas identified as needing to be fixed will be corrected within 48 hours. |