INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on July 1, 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 Focus 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:
|
Plan of Correction
|
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 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 four of seven client records reviewed.
Client #1 was admitted on February 3, 2021 and was discharged on April 30, 2021. There was documentation of a facsimile sent to an insurance company; however, there was no release of information form for that insurance company documented in the client record.
Client #2 was admitted on February 26, 2021 and was an active client at the time of the inspection. A urinalysis was completed on the client on March 31, 2021 and May 16, 2021; however, there was no release of information form for the laboratory documented in the client record.
Client 3 was admitted on April 29, 2021 and was an active client at the time of the inspection. A urinalysis was completed on the client on April 30, 2021 and May 16, 2021; however, there was no release of information form for the laboratory documented in the client record.
Client # 5 was admitted on August 18, 2020 and was discharged on April 7, 2021. A urinalysis was completed on the client on April 6, 2021 and June 14, 2021; however, there was no release of information form for the laboratory documented in the client record.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Program Administrator and Division Director reviewed the policy on Confidentiality to ensure that all new admissions to Gaudenzia, Focus House has signed consent authorizing Gaudenzia, Focus House staff to provide information to all external entities regarding their protected information.
Division Director assigned Confidentiality training to all staff and instructed all staff to complete the Confidentiality training in the Gaudenzia, Relias Learning training site.
Client #1 completed consent authorizing information required for his insurance company.
Consents for Client #2, #3, and #5 were completed for Atlantic Diagnostic Laboratory to continue the service provided to Gaudenzia, Focus House for the processing of urinalysis.
The consents were faxed to Atlantic Diagnostic Laboratory for them to have on file.
|
709.34 (c) (5) 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:
(5) Outbreak of a contagious disease requiring CDC notification.
|
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 outbreak of a contagious disease requiring CDC notification.
It was documented in the unusual incident log that there was a COVID-19 outbreak in the facility beginning November 27, 2020 that lasted through until mid-December. The Health Department was notified of the outbreak on December 1, 2020; however, a written unusual incident report was not filed with the Department.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Division Director review the incident reporting policies, according to Department of Drug and Alcohol Programing, Bureau of Licensing (DHS) and Department of Behavioral Health and Intellectual disabilities with Gaudenzia, Focus House Staff.
Each staff member was provided with a copy of all polices for their own review.
Division Director has requested that all significant incident reports be faxed to her along with sending them the designated organizations.
All significant incident reports will be reported directly to the Division Director within 24 hours of the incident.
The Division Director will immediately report all significant incidents to the organizations leaders immediately upon becoming aware.
The Division Director will observe written significant incident report to confirm that it has been completed, forwarded to designated organization and is filed appropriately for review.
|