INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 7, 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, Inc. Winner Co-Occurring Women and Children Program 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on the review of four personnel records, the project failed to ensure that one employee received a minimum of six hours of HIV/AIDS and at least four hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum.
Employee #4 was employed as a support staff person on March 19, 2018 and was to have the communicable disease training by March 19, 2020; however, there was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
704.11(c) (1) Mandatory Communicable Disease Training:
This standard was reviewed with the Program Director on August 3rd, 2021. Employee #4 will complete a minimum of six hours of HIV/AIDS training and at least four hours of TB/STD training by August 31st, 2021. Going forward, within 3 months of being hired, Staff will complete a minimum of six hours of HIV/AIDS training and at least four hours of TB/STD training. Program Director will monitor the HR Training Grid monthly to ensure Staff are in compliance with 704.11(c) (1).
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705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on the physical plant inspection, the facility failed to keep frozen food at or below 0 degrees Fahrenheit.
The thermometer inside the kitchen freezer read 24 degrees Fahrenheit.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
705.7(b) (5) Food Service:
The freezer was serviced on July 8th, 2021. Freezer temperature logs are in place at the facility and will continue to be checked daily by the Cook and/or House Manager. The Cook and/or House Manager will inform the Program Director of freezer temperatures above 0 degrees Fahrenheit. The Program Director will monitor the logs weekly to ensure that frozen foods are being kept at 0 degrees Fahrenheit. In addition, the Quality Assurance Department will also monitor temperature logs during quarterly site visits and the Compliance Department will conduct an annual review of the Plan of Correction in order to ensure compliance with 705.7(b) (5).
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705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on the review of the fire drill log from July 2020 through June 2021, the facility failed to prepare alternate exit routes to be used during fire drills.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
705.10(d) (6) Fire Safety:
The Program Director completed an in-service training on August 3rd, 2021 with all Staff on how to properly conduct a fire drill, which will include the importance of using alternate exit routes. Going forward, the Program Director will review all fire drill forms within 24 hours to ensure that alternate exit routes are used during fire drills. Additionally, the Quality Assurance Department will monitor fire drill logs during quarterly site visits and the Compliance Department will conduct an annual review of the Plan of Correction in order to ensure full compliance with 705.10(d) (6).
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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.
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Observations
Based on a review of client records, the project failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in two of seven client records reviewed.
Client #6 was admitted on February 25, 2021 and was discharged on June 11, 2021. A release of information form to the funding source, signed and dated by the client on February 25, 2021, allowed for the release of treatment plans, physical/medical records, discharge summary, medications records, assessment and emergency information, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #7 was admitted on January 13, 2021 and was discharged on June 12, 2021. A release of information form for a primary care physician, signed and dated by the client on January 13, 2021, did not document the specific information to be disclosed.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
709.28(c) (2) Confidentiality:
The Program Director conducted an in-service training on July 30, 2021 with clinical staff regarding the specific information to be disclosed when completing consents. Going forward, the Program Director and/or Clinical Supervisor will conduct bi-weekly chart audits to ensure that consent forms are completed appropriately. The Division Director will complete monthly random chart audits to monitor compliance with this standard. In addition, the Quality Assurance Department will conduct quarterly chart audits to include consents and the Compliance Department will conduct an annual review of the Plan of Correction in order to ensure full compliance with 709.28 9(c) (2). |
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 #7 was admitted on January 13, 2021 and was discharged on June 12, 2021. A release of information form for a primary care physician, signed and dated by the client on January 13, 2021, 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
709.28(c) (3) Confidentiality:
The Program Director conducted an in-service training on July 30th, 2021 with clinical staff regarding indicating the purpose of disclosure when completing consents. Going forward, the Program Director/Clinical Supervisor will conduct bi-weekly chart audits to ensure that all consent forms are completed appropriately. The Division Director will complete monthly random chart audits to monitor compliance with this standard. In addition, the Quality Assurance Department will conduct quarterly chart audits to include consents and the Compliance Department will conduct an annual review of the Plan of Correction in order to ensure full compliance with 709.28 9(c) (3). |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on the review of client records, the project failed to notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project in two of two applicable client records.
Client #5 was admitted on February 9, 2021 and was involuntarily discharged on April 1, 2021. It was not documented in the client record that the client received written notification of the decision to involuntarily terminate the client ' s treatment.
Client #6 was admitted on February 25, 2021 and was involuntarily discharged on June 11, 2021. It was not documented in the client record that the client received written notification of the decision to involuntarily terminate the client ' s treatment.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
709.33 (a) Notice of Termination:
The Program Director conducted an in-service training on July 30th, 2021 with clinical staff regarding completing Notices of Termination and the importance of including the reason for termination. All Notice of Terminations will be completed upon a Client's discharge by the Counselor/Clinical Supervisor/Program Director. Going forward, the Program Director/Clinical Supervisor will conduct bi-weekly chart audits to ensure that all notice of terminations are completed at discharge. The Division Director will complete monthly random chart audits to monitor compliance with this standard. Additionally, the Quality Assurance Department will conduct quarterly chart audits and the Compliance Department will conduct an annual review of the Plan of Correction in order to ensure full compliance with 709.33 (a). |
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on the review of client records, the project failed to ensure that clients had an opportunity to request reconsideration of the decision to terminating treatment in two of two applicable client records reviewed.
Client #5 was admitted on February 9, 2021 and was involuntarily discharged on April 1, 2021. It was not documented in the client record that the client had an opportunity to request reconsideration of the decision to terminating treatment.
Client #6 was admitted on February 25, 2021 and was involuntarily discharged on June 11, 2021. It was not documented in the client record that the client had an opportunity to request reconsideration of the decision to terminating treatment.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
709.33 (b) Notice of Termination:
The Program Director conducted an in-service training on July 30th, 2021 with Clinical Staff regarding the Client's right to request reconsideration of a decision terminating treatment. The Counselor/Clinical Supervisor/Program Director will ensure that Clients are given the opportunity to request reconsideration of a decision terminating treatment once Clients are given the Notice of Termination. Going forward, the Program Director/Clinical Supervisor will conduct bi-weekly chart audits to ensure that Clients were indeed given the opportunity to request reconsideration of a decision terminating treatment. The Division Director will complete monthly random chart audits to monitor compliance with this standard. Additionally, the Quality Assurance Department will conduct quarterly chart audits and the Compliance Department will conduct an annual review of the Plan of Correction in order to ensure full compliance with 709.33 (b). |
709.34 (c) (1) 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:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on the review of the unusual incident log, the project failed to file a written unusual incident report with the Department within three business days following an unusual incident involving a physical or sexual assault by staff or a client.
On November 12, 2020, a client physically assaulted another client. A written unusual incident report was not filed with the Department.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
709.34(c) (1) Reporting of Unusual Incidents:
The Program Director conducted an in-service training on August 3rd, 2021 with all Staff on how to properly complete and submit Unusual Incidents Reports to DDAP, which will include completing an incident report within 3 business days following an unusual incident involving a physical or sexual assault by staff or a client. Going forward, the Program Director will review all incident reports within 24 hours of any incident to ensure that any unusual incidents are reported to DDAP within 3 business days. Additionally, the Quality Assurance Department will monitor incident reports during quarterly site visits and the Compliance Department will conduct an annual review of the Plan of Correction in order to ensure full compliance with 709.34(c) (1). |
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 incident log, the project failed to file a written unusual incident report with the Department within three business days following an unusual incident involving an event at the facility requiring the presence of police, fire or ambulance personnel.
On May 2, 2021, ambulance personnel arrived at the facility to transport a client to the hospital. A written unusual incident report was not filed with the Department.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
709.34(c) (4) Reporting of Unusual Incidents:
The Program Director conducted an in-service training on August 3rd, 2021 with all Staff on how to properly complete and submit Unusual Incidents Reports to DDAP, which will include completing an incident report within 3 business days following an unusual event at the facility that requires the presence of police, fire, or ambulance personnel. Going forward, the Program Director will review all incident reports within 24 hours of any incident to ensure that any unusual incidents are reported to DDAP within 3 business days. Additionally, the Quality Assurance Department will monitor incident reports during quarterly site visits and the Compliance Department will conduct an annual review of the Plan of Correction in order to ensure full compliance with 709.34(c) (4). |