INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 23, 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 Together 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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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 a review of personnel records and the facility's Staffing Requirement Facility Summary Report form, the project failed to ensure that one employee received the minimum of six hours of HIV/AIDS training and at least four hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #3 was hired as a counselor on September 16, 2019 and was due to have the communicable disease trainings no later than September 16, 2020. 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
Director has completed a full review of all staff qualifications.
Employee #3 will complete the HIV/AIDS training and the TB/STD training by August 31, 2021.
In an effort to ensure ongoing compliance all staff training records will be reviewed by the Director, in coordination with the Regional Human Resource Manager, annually.
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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 #4 was admitted on March 17, 2021 and was discharged on May 13, 2021. A release of information form for the funding source was not documented in the client record.
Client #5 was admitted on March 22, 2021 and was discharged on May 5, 2021. A release of information form for the funding source was not documented in the client record.
Client #6 was admitted on March 2, 2021 and was discharged on April 15, 2021. A release of information form for the correct funding source was not documented in the client record. Additionally, there was communication between staff and another treatment facility on April 9, 2021; however, there was no release of information for this treatment facility documented in the client record
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Program Director and/or Clinical Supervisor will review Confidentiality and Releases of Information with all clinical staff during staff in-service by 08/06/2021.
In addition, the Program Director and/or Clinical Supervisor will monitor confidential releases of information during monthly file audits and address discrepancies during staff supervisions.
The CQI department will monitor confidentiality and releases of information during quarterly CQI file audits and will report findings to the Program Director.
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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 three of seven client records reviewed.
Client #2 was admitted on May 19, 2021 and was an active client at the time of the inspection. A release of information form the funding source, signed and dated by the client on May 22, 2021, allowed for the release of psychological/psychiatric evaluations, treatment plans, case consultations, mental health records, physical/medical record, discharge summary, progress notes, medication records, assessments, emergency information and demographics, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #3 was admitted on May 11, 2021 and was an active client at the time of the inspection. A release of information form for the funding source, signed and dated by the client on May 11, 2021, did not document the specific information to be disclosed.
Client #6 was admitted on March 2, 2021 and was discharged on April 15, 2021. A release of information form a funding source, signed and dated by the client on March 2, 2021, allowed for the release of psychological/psychiatric evaluations, treatment plans, case consultations, mental health records and progress notes, all of which exceeds the limits established by 4 Pa. Code 255.5.
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
Program Director and/or Clinical Supervisor will review Confidentiality and Releases of Information with all clinical staff during staff in-service by 08/06/2021.
In addition, the Program Director and/or Clinical Supervisor will monitor confidential releases of information during monthly file audits and address discrepancies during staff supervisions.
The CQI department will monitor confidentiality and releases of information during quarterly CQI file audits and will report findings to the Program Director.
In regards to Client #2, was discharged as of 7/6/2021.
In regards to Client #3, was discharged as of 06/22/2021.
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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 two of seven client records reviewed.
Client #1 was admitted on May 28, 2021 and was an active client at the time of the inspection. A release of information form for the funding source, signed and dated by the client on May 23, 2021, did not document the purpose of disclosure.
Client #7 was admitted on February 3, 2021 and was discharged on March 5, 2021. A release of information form for a family member, signed and dated by the client on February 17, 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
Program Director and/or Clinical Supervisor will review Confidentiality and Releases of Information with all clinical staff during staff in-service by 7/30/2021.
In addition, the Program Director and/or Clinical Supervisor will monitor confidential releases of information during monthly file audits and address discrepancies during staff supervisions.
The CQI department will monitor confidentiality and releases of information during quarterly CQI file audits and will report findings to the Program Director.
In regards to Client #1 the release of information for the funding source cited was revoked on 07/19/2021 and new release of information was completed.
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709.28 (c) (5) 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:
(5) Dated signature of witness.
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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 a dated witness signature in two of seven client records reviewed.
Client #1 was admitted on May 28, 2021 and was an active client at the time of the inspection. A release of information form for the emergency contact, signed and dated by the client on May 28, 2021, did not document a dated witness signature.
Client #6 was admitted on March 2, 2021 and was discharged on April 15, 2021. A release of information form for a funding source, signed and dated by the client on May 28, 2021, did not document a dated witness signature.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Program Director and/or Clinical Supervisor will review Confidentiality and Releases of Information with all clinical staff during staff in-service by 7/30/2021.
In addition, the Program Director and/or Clinical Supervisor will monitor confidential releases of information during monthly file audits and address discrepancies during staff supervisions.
The CQI department will monitor confidentiality and releases of information during quarterly CQI file audits and will report findings to the Program Director.
In regards to Client #1, the release of information for the emergency contact was revoked on 7/23/21 and a new release was completed.
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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.
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Observations
Based on the review of client records, the project failed to offer a copy of the release of information forms in four of seven client records reviewed.
Client #1 was admitted on May 28, 2021 and was an active client at the time of the inspection. There was no documentation that the client was offered a copy of the release of information form for the funding source, signed and dated by the client on May 23, 2021.
Client #3 was admitted on May 11, 2021 and was an active client at the time of the inspection. There was no documentation that the client was offered a copy of the release of information form for the funding source, signed and dated by the client on May 11, 2021.
Client #6 was admitted on March 2, 2021 and was discharged on April 15, 2021. There was no documentation that the client was offered a copy of the release of information form for a funding source, signed and dated by the client on March 2, 2021.
Client #7 was admitted on February 3, 2021 and was discharged on March 5, 2021. There was no documentation that the client was offered a copy of the release of information forms for a case manager and family member, signed and dated by the client on February 7, 2021.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Program Director and/or Clinical Supervisor will review Confidentiality and Releases of Information with all clinical staff during staff in-service by 7/30/2021.
This includes ensuring the box that reviews offering a copy of the release will be checked indicating if the client accepted or refused a copy.
In addition, the Program Director and/or Clinical Supervisor will monitor confidential releases of information during monthly file audits and address discrepancies during staff supervisions.
The CQI department will monitor confidentiality and releases of information during quarterly CQI file audits and will report findings to the Program Director.
In regards to Client #1 as of 7/23/2021 all releases of information have been reviewed and corrected. Client#1 has been offered a copy of these releases.
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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 logbook, the project failed to file a written unusual incident report with the Department within three business days following an unusual incident involving the physical or sexual assault by staff or a client.
There was documentation that a client assaulted another client on May 19, 2021; however, there was no documentation that a written unusual incident report was ever filed with the Department.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Program Director has reviewed and forwarded all unusual incident reports noted as of 7/23/21.
The Program Director will review the incident log on a weekly basis to ensure that all reports are sent to the Department within 3 days.
In addition, on a quarterly basis the CQI Department will review the incident log to ensure compliance and report findings to the Program Director.
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709.51(b)(7) LICENSURE Preliminary Tx. Plan.
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on the review of client records, the project failed to document a preliminary treatment and rehabilitation plan during the intake procedures as per their policy in four of seven client records reviewed.
Client #2 was admitted on May 19, 2021 and was an active client at the time of the inspection. A preliminary treatment plan was not documented in the record until May 24, 2021.
Client #3 was admitted on May 11, 2021 and was an active client at the time of the inspection. A preliminary treatment plan was not documented in the record until May 16, 2021.
Client #6 was admitted on March 2, 2021 and was discharged on April 15, 2021. A preliminary treatment plan was not documented in the record until March 9, 2021.
Client #7 was admitted on February 3, 2021 and was discharged on March 5, 2021. A preliminary treatment plan was not documented in the record until February 8, 2021.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Program Director and/or Clinical Supervisor will review Treatment Plans including timelines for updates with all clinical staff during an in-service by 08/06/2021. This training will include a detail review of the workflows for each level of care.
In addition, the Program Director and/or Clinical Supervisor will monitor treatment plan updates during monthly file audits and address discrepancies during staff supervisions.
The CQI department will monitor treatment plan updates during quarterly CQI file audits and will report findings to the Program Director.
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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 six of seven client records reviewed.
Client #2 was admitted on May 19, 2021 and was an active client at the time of the inspection. A comprehensive treatment and rehabilitation plan competed on May 24, 2021, indicated that the client was to receive one individual counseling session per week; however, there were no individual counseling sessions documented in the client record for the weeks of May 30, 2021 through June 19, 2021.
Client #3 was admitted on May 11, 2021 and was an active client at the time of the inspection. A comprehensive treatment and rehabilitation plan competed on May 16, 2021, indicated that the client was to receive one individual counseling session per week; however, there were no individual counseling sessions documented in the client record for the week of June 13, 2021 through June 19, 2021.
Client #4 was admitted on March 17, 2021 and was discharged on May 13, 2021. A comprehensive treatment and rehabilitation plan competed on March 22, 2021, indicated that the client was to receive one individual counseling session per week; however, there were no individual counseling sessions documented in the client record for the weeks of March 28, 2021 through April 3, 2021 and April 18, 2021 through April 24, 2021.
Client #5 was admitted on March 22, 2021 and was discharged on May 5, 2021. A comprehensive treatment and rehabilitation plan competed on March 25, 2021, indicated that the client was to receive one individual counseling session per week; however, there were no individual counseling sessions documented in the client record for the weeks of April 4, 2021 through April 10, 2021, April 11, 2021 through April 17, 2021 and April 25, 2021 through May 1, 2021.
Client #6 was admitted on March 2, 2021 and was discharged on April 15, 2021. A comprehensive treatment and rehabilitation plan competed on March 9, 2021, indicated that the client was to receive one individual counseling session per week; however, there were no individual counseling sessions documented in the client record for the week of March 7, 2021 through March 13, 2021.
Client #7 was admitted on February 3, 2021 and was discharged on March 5, 2021. A comprehensive treatment and rehabilitation plan competed on February 8, 2021, indicated that the client was to receive one individual counseling session per week; however, there were no individual counseling sessions documented in the client record for the week of March 14, 2021 through March 20, 2021.
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
Program Director and/or Clinical Supervisor will review Treatment Plans including the provision of services in accordance with the treatment plan. The Director and/or Clinical Supervisor will also review the proper documentation of "missed" sessions, with all clinical staff during an in-service by 08/06/2021. Workflows for this level of care will also be reviewed in detailed.
In addition, the Program Director will monitor the provision of services during monthly file audits and address discrepancies during staff supervisions.
The CQI department will monitor the provision of services during quarterly CQI file audits and will report findings to the Program Director.
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709.53(a)(8) LICENSURE Case Consultation Notes
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:
(8) Case consultation notes.
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Observations
Based on the review of client records, the project failed to document a complete client record on an individual that included case consultation notes in four of seven client records reviewed.
Client #4 was admitted on March 17, 2021 and was discharged on May 13, 2021. Case consultation notes were not documented in the client record.
Client #5 was admitted on March 22, 2021 and was discharged on May 5, 2021. Case consultation notes were not documented in the client record.
Client #6 was admitted on March 2, 2021 and was discharged on April 15, 2021. Case consultation notes were not documented in the client record.
Client #7 was admitted on February 3, 2021 and was discharged on March 5, 2021. Case consultation notes were not documented in the client record.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Program Director and/or Clinical Supervisor will review Case Consultation with all clinical staff during an in-service by 08/06/2021. Per our internal workflows for this level of care, initial case consults are due within 15 days of admission and then every 90-days on an ongoing basis.
In addition, the Program Director and/or Clinical Supervisor will monitor Case Consultations during monthly file audits and address discrepancies during staff supervisions.
The CQI department will monitor Case Consultations during quarterly CQI file audits and will report findings to the Program Director.
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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 the review of client records, the project failed to document a complete client record on an individual that included a discharge summary in three of four applicable client records reviewed.
Client #4 was admitted on March 17, 2021 and was discharged on May 13, 2021. A discharge summary was not documented in the client record.
Client #5 was admitted on March 22, 2021 and was discharged on May 5, 2021. A discharge summary was not documented in the client record.
Client #6 was admitted on March 2, 2021 and was discharged on April 15, 2021. A discharge summary was not documented in the client record.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Program Director and/or Clinical Supervisor will review Discharge Documentation with all clinical staff during an in-service by 08/06/2021.
In addition, the Program Director and/or Clinical Supervisor will monitor Discharge summaries and discharge documentation during monthly file audits and address discrepancies during staff supervisions.
The CQI department will monitor Discharge summaries and discharge documentation during quarterly CQI file audits and will report findings to the Program Director.
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