INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 6, 2018 through June 7, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. 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:
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Plan of Correction
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705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on the physical plant inspection conducted on 6/7/18 between 9:30 am and 10:00 pm, the facility failed to ensure that all heaters in the facility were permanently mounted or installed as there was a space heater discovered underneath the table against the back wall in the assessment room, which was located across from the front desk.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Division Director removed the space heater from the facility on 6/7/18. All Staff members were instructed not to have space heaters in offices. The Program Director and Program Supervisor will ensure compliance through regular routine safety/maintenance checks throughout the facility. |
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 total review of 21 client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in 3 client records.
Client # 2 was admitted on 8/15/16 and was discharged 5/7/18. There was no release of information form signed to the funding source; however, there was documentation that communication was made between the facility and the funding source during the client's treatment episode.
Client # 3 was admitted on 5/21/18 and discharged 5/21/18. There was no release of information form signed to the funding source; however, there was documentation that communication was made between the facility and the funding source during the client's treatment episode.
Client # 6 was admitted on 5/25/18 and discharged 5/25/18. There was no release of information form signed to the funding source; however, there was documentation that communication was made between the facility and the funding source during the client's treatment episode.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Division Director has reviewed Confidentiality regulations and proper procedures for completing consents to release information with all staff members. The Program Director and Program Supervisor will continue supervision with all staff and provide on going training to ensure necessary release of information are completed per licensing regulations. The Program Director and Program Supervisor will ensure continued compliance by regular weekly chart audits on open and discharged charts in conjunction with CQI policies and CQI Director. |