INITIAL COMMENTS
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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 October 15, 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 Inc. Harrisburg Concept 90 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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705.10 (b) (6) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(6) Maintain all smoke detectors and fire alarms so that each person with a hearing impairment will be alerted in the event of a fire, if one or more residents or staff persons are not able to hear the smoke detector or fire alarm system.
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Observations
Based on a physical plant inspection, the facility failed to maintain smoke detectors and fire alarm so a hearing-impaired person would be alerted in the event of a fire.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director has acquisitioned the purchase of a vibro-tactile alarm device for placement under the pillow or mattress to alert a hearing and/or visually impaired individual of fire alarm.
All staff will be trained on use of the device.
The device will be checked for operation on a monthly basis by designated staff safety representative and included on the Safety Committee Report.
Targeted resolution date: 11/21/20
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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 facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in client record #'s 4 and 6.
Client #4 was admitted on September 18, 2020 and was an active client as of the date of the inspection. Consent to release forms were signed and dated on September 18, 2020 to the funding sources and county agencies that allowed for the release of the discharge summary, referral summary, treatment plans, Drug and Alcohol information, court orders, assessments, lab results, progress notes, physical and medication records, psych evaluation and mental health records.
Client #6 was admitted on June 29, 2020 and was discharged on September 29, 2020. A consent to release form was signed and dated on July 23, 2020 to a county agency that allowed for the release of the psychological evaluations, mental health records and physical and medical records.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Clinical Supervisor/Program Director reviewed the 4PACode255.5 confidentiality regulations with all staff and provided re-training to assure that all consents to release information conform with the code and identify only information for release within the allowable limits.
The Clinical Supervisor will monitor ongoing conformance via monthly record audits and reported to the Continuous Quality Improvement Department.
Targeted Resolution date: 11/10/20
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709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of client records and conversation with the clinical supervisor, the facility failed to ensure that all work done by clients within the facility is an integral part of the treatment and rehabilitation plan in all client records.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Clinical Supervisor reviewed with all Clinicians the regulation requiring that all work performed within the facility be included in the individual treatment plan as a therapeutic tool.
The Clinical Supervisor will monitor ongoing conformance via monthly record reviews and reporting to the Continuous Quality Improvement Department.
Target Resolution date: 11/10/2020 |