INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on April 22, 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. 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
|
705.7 (b) (6) 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:
(6) Store all food items off the floor.
|
Observations
Based on a physical plant inspection, the facility failed to ensure that all food was stored off the floor as dry goods located in the first-floor pantry were stored directly on the floor.
These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
In accordance with state regulation 705.7 (b) (6) Food Service: On 04/22/2021, All items that were on the floor in the pantry, during the physical plant inspection were removed from the floor and placed on shelves, immediately following the site visit, by the program director.
On 04/26/2021, a staff meeting was conducted by the program director. All staff were educated on proper food storage compliance.
To avoid reoccurrence, staff will document and correct any improper food storage; utilizing our monthly Health and Safety report, which is reviewed and submitted monthly, by the program director to our internal Quality Assurance Department.
|
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.
|
Observations
Based on the review of seven client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in one client record.
Client #3 was admitted on November 3, 2020 and was still active at the time of the inspection. There was documentation that a phone call was placed to the funding source on April 9, 2021; however, there was no proper consent to release information form signed by the client prior to disclosure.
These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
In accordance with 709.28 (c) Licensure Confidentiality. Client #3 was admitted to the program on 11/03/2020. Despite the length of time client #3 spent in the program, a consent was not obtained from the client, for the program to share information with her insurance company. On 04/26/21, Client #3's, primary counselor obtained Client's consent for her insurance company.
New program director was hired on 02/18/21 and began: changing / establishing / implementing existing organizational practices (including admission day consents) for future admissions.
Internal audits by the program director; beginning 05/24/21 will also assist with programmatic compliance for confidentiality. |
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 seven 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 one client record.
Client #4 was admitted on February 5, 2021 and was still active at the time of the inspection. A consent to release form to a government agency was signed and dated on February 5, 2021 that allowed for the release of psych evaluations, treatment plans, progress notes, medication records, assessments, case consults, mental health records, physical and medical examinations and discharge summaries.
These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
In accordance with 709.28 Licensure Confidentiality regarding consent(s) to a governmental agency; information is to be limited as outlined in PA 255.5 regulations.
On 04/26/2021, primary counselor of Client # 4 changed the consent of a governmental agency to reflect the limited information, prescribed under PA 255.5 regulations.
By 06/01/2021, the newly appointed program director will check all active charts and will make necessary changes to reflect compliance with 255.5 regulations. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
|
Observations
Based on a review of seven client records, the facility failed to ensure that all client records included documentation of a physical examination in three records reviewed.
Client record #1 was admitted on November 13, 2020 and was still active at the time of inspection.
Client #2 was admitted on October 15, 2020 and was still active at the time of the inspection.
Client #3 was admitted on November 3, 2020 and was still active at the time of the inspection.
These findings were discussed with facility staff during the inspection process.
This is a repeat citation from the October 30, 2020 inspection.
|
Plan of Correction
709.51 (b) (5) Licensure Physical Examination: Intake procedures shall include physical examinations: Upon the hire of the current program director, the former practice of accepting a resident without a current physical examination was discontinued.
Prior to 04/22/2021, the new program director would ask for a current copy of a potential residents physical examination at the time the interview is scheduled or the day before admission.
Beginning 06/01/2021, the Program Director will be auditing the client charts at a minimum of one time monthly. Deficits will be documented and corrected, if possible.
|
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
|
Observations
Based on a review of seven client records, the facility failed to document treatment plan updates within the regulatory timeframe in four records reviewed.
Client #1 was admitted on November 13, 2020 and was still active at the time of the inspection. A treatment plan update was completed on February 23, 2021 and the next update was due no later than March 23, 2021; however, there was no update documented in the record at the time of the inspection.
Client #2 was admitted on October 15, 2020 and was still active at the time of the inspection. A treatment plan update was completed on January 13, 2021 and the next update was due no later than February 13, 2021; however, there was no update documented in the record at the time of the inspection.
Client #3 was admitted on November 3, 2020 and was still active at the time of the inspection. A treatment plan update was completed on February 23, 2021 and the next update was due no later than March 23, 2021; however, there was no update until April 14, 2021.
Client #4 was admitted on February 5, 2021 and was still active at the time of the inspection. A treatment plan update was completed on February 16, 2021 and the next update was due no later than March 16, 2021; however, there was no update documented in the record at the time of the inspection.
These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
709.52 (b) Licensure Tx Plan Update: In accordance with licensure requirements, treatment plans need to be updated every 15 days for short term and every 30 days for long term stays.
As of 06/01/2021~ all current client files will be audited on a monthly bases, by the program director to ensure compliance with regulation 709.52, Updated Tx Planning. Treatment plan due dates will be recorded on our daily census as an extra measure. |
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.
|
Observations
Based on a review of seven client records, the facility failed to ensure that all work done by the client at the project is an integral part of his treatment and rehabilitation plan in all seven records reviewed.
These findings were discussed with facility staff during the inspection process.
This is a repeat citation from the October 30, 2020 inspection.
|
Plan of Correction
709.53 (a) (12) Licensure, Work as Treatment:
By 06/01/2021, All treatment plans will include all work completed by the client as an integral part of her treatment plan. Work therapy as treatment will be elaborated upon and assimilated as activities for daily living.
05/21/2021 Program Director and Counselor will review current cases to expand upon work therapy as a goal for / in activities for daily living. All future residents of the program will also have similar goals if applicable at admission. |