INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 8, 2019 of Gaudeniza Inc. Broad Street by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Gaudenzia Inc. Broad Street 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(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
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Observations
Based on a review of the policy and procedure manual, the facility failed to follow their policy in regard to completion of the assessment of staff training needs. The Plan for Assessing Staff Training Needs policy stated, "The training plan shall be ready for implementation effective Jan. 31st of each year." The overall training plan for the project was not completed until May 16th, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The relevant Gaudenzia Policy has been revised to state that, "Program-level training needs assessments are due to the Training department by the end of January of each year. Upon receipt of the program-level annual assessments of staff training needs, the Director of Training and Education, in collaboration with the Project Director, will review the assessments in detail and develop a plan to address the training needs of the agency. The annual agency-wide training plan shall be ready for implementation no later than April 30th of each year." The Gaudenzia Director of Training and Education will ensure that this is completed within the designated timeframe each year. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel files, employee #1 was not trained in the use of the fire extinguisher upon employment. Employee #1 was hired on March 4, 2019 and was still employed at the time of the inspection. There was no documentation that the employee received the training as of the date of this inspection July 8th, 2019.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director completed this training on 6/7/19 and documentation of this has been placed in his file. All relevant staff within the HR and Training departments will review the DDAP 705.10 (c) (4) - 705.28 (c) (4) regulations by 7/31/19, and as the head of the Training department, the Director of Training and Education will be ultimately responsible for ensuring that all staff (to include administrative staff) receive required fire extinguisher training upon hire. Training department staff will review all staff files during the orientation process to ensure that this training is completed. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based upon a review of personnel files, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies. Employee #1 was hired on March 4, 2019 and was still employed at the time of the inspection. There was no documentation in employee #1 's personnel file indicating that the employee had been trained on what to do during emergencies as of the date of this inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director completed this training on 6/7/19 and documentation of this has been placed in his file. All relevant staff within the HR and Training departments will review the DDAP 705.10 (d) (3) regulations by 7/31/19, and as the head of the Training department, the Director of Training and Education will be ultimately responsible for ensuring that all staff (to include administrative staff) receive required emergency procedure training upon hire. Training department staff will review all staff files during the orientation process to ensure that this training is completed. |
705.24 (2) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
During a physical plant inspection on July 8, 2019, the facility failed to have individual paper towels or a mechanical dryer in all three of the male dorm bathrooms. There was no wall mirror in the large female dorm bathroom.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Paper towel dispensers installed on 7/10/2019 in all client bathrooms. The maintenance department was contacted on 7/9/2019 and the mirror will be installed by 8/23/2019. Program Director will conduct weekly facility walk throughs to ensure ongoing compliance |
705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection on July 8, 2019, the facility failed to ensure that water temperature does not exceed 120F. The water temperature in the bathroom was 127.5 F.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Facility purchased a thermometer on 7/15/2019 to ensure weekly compliance surrounding water temperatures. Facility director or designee will continue on-going weekly monitoring of water temperature. On 7/15/2019 water temperature was checked and the temperatures all read with-in compliance. |
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 1, 2, 3, 4, 5, 6, and 7.
Client # 1 was admitted on May 3, 2019 and was still active at the time of inspection. An informed and voluntary consent to release form was signed and dated on May 15, 2019 to probation that allowed for the release of treatment plans, updates and biopsycho assessments. Additionally, an informed and voluntary consent to release form to the funding source was signed and dated May 3, 2019 that allowed for the release of treatment plans, treatment goals, urine drug screenings, historical data, housing options, and discharge planning.
Client # 2 was admitted on April 5, 2019 and was still active at the time of inspection. An informed and voluntary consent to release form was signed and dated on April 5, 2019 to the funding source that allowed for the release of treatment plans, treatment goals, urine drug screenings, historical data, housing options, and discharge planning.
Client # 3 was admitted on February 1, 2019 and was still active at the time of inspection. An informed and voluntary consent to release form was signed and dated on February 1, 2019 to the funding source that allowed for the release of treatment plans, treatment goals, urine drug screenings, historical data, housing options, and discharge planning.
Client # 4 was admitted on April 17, 2019 and was discharged on July 8, 2019. An informed and voluntary consent to release form was signed and dated on April 17, 2019 to the funding source that allowed for the release of treatment plans, treatment goals, urine drug screenings, historical data, housing options, and discharge planning.
Client #5 was admitted on March 15, 2019 and was still active at the time of inspection. An informed and voluntary consent to release form was signed and dated on March 15, 2019 to the funding source that allowed for the release of treatment plans, treatment goals, urine drug screenings, historical data, housing options, and discharge planning.
Client # 6 was admitted on January 15, 2019 and was discharged on February 22, 2019. An informed and voluntary consent to release form was signed and dated on January 15, 2019 to the funding source that allowed for the release of treatment plans, treatment goals, urine drug screenings, historical data, housing options, and discharge planning.
Client # 7 was admitted on November 8, 2018 and was discharged on February 14, 2019. An informed and voluntary consent to release form was signed and dated on November 8, 2018 to the funding source that allowed for the release of treatment plans, treatment goals, urine drug screenings, historical data, housing options, and discharge planning.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Gaudenzia now utilizes an electronic record system which includes a release form which is designed to minimize the potential for over-disclosure. The Program Director will ensure that all staff are utilizing the correct form. For all individuals who are active in the program, a new release form will be completed, documenting the limitation of disclosure to items specified in 255.5. The Program Director will ensure that this will be completed by 8/23/19. On a regular basis, the Clinical Supervisor will review releases in clinical supervision sessions to ensure that all releases are limited to the items allowed by law. In addition, the Program Director will conduct an in-service review of all relevant confidentiality regulations during an all staff meeting. This will occur by 8/31/19. |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on a review of the facility's client rights, the facility failed to include that the project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Continuous Quality Improvement Director has revised the Gaudenzia Client Bill of Rights to accurately reflect the DDAP 709.30 regulations regarding a client's right to inspect their own record and actions they make take in this regard. The document now states that, "The following rights are affirmed... The right to examine one's own record within the guidelines approved by the agency in accordance with Federal regulations 42 CFR, and rebut any information in their record by inserting a counter statement of clarification or correction. The agency may temporarily remove portions of the record prior to inspection if the Director determines that the information may be detrimental if presented to the client. Reasons for removal of sections will be documented in the record. Clients have the right to appeal a decision limiting access to their records to the director. Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records." This revised Bill of Rights document will be distributed to all programs by 7/26/19. The Program Director will review it with all staff and it will be incorporated into the client orientation manuals and signed by all active clients by 8/2/19. The Program Director will ensure that as a part of the regular, monthly CQI Chart Audit process, the current version of the Client Bill of Rights is being completed. |
709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on a review of the facility's client rights, the facility failed to include that the clients have the right to appeal a decision limiting access to their records to the director.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Continuous Quality Improvement Director has revised the Gaudenzia Client Bill of Rights to accurately reflect the DDAP 709.30 regulations regarding a client's right to inspect their own record and actions they make take in this regard. The document now states that, "The following rights are affirmed... The right to examine one's own record within the guidelines approved by the agency in accordance with Federal regulations 42 CFR, and rebut any information in their record by inserting a counter statement of clarification or correction. The agency may temporarily remove portions of the record prior to inspection if the Director determines that the information may be detrimental if presented to the client. Reasons for removal of sections will be documented in the record. Clients have the right to appeal a decision limiting access to their records to the director. Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records." This revised Bill of Rights document will be distributed to all programs by 7/26/19. The Program Director will review it with all staff and it will be incorporated into the client orientation manuals and signed by all active clients by 8/2/19. The Program Director will ensure that as a part of the regular, monthly CQI Chart Audit process, the current version of the Client Bill of Rights is being completed. |
709.30 (5) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Based on a review of the facility's client rights, the facility failed to include that the clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Continuous Quality Improvement Director has revised the Gaudenzia Client Bill of Rights to accurately reflect the DDAP 709.30 regulations regarding a client's right to inspect their own record and actions they make take in this regard. The document now states that, "The following rights are affirmed... The right to examine one's own record within the guidelines approved by the agency in accordance with Federal regulations 42 CFR, and rebut any information in their record by inserting a counter statement of clarification or correction. The agency may temporarily remove portions of the record prior to inspection if the Director determines that the information may be detrimental if presented to the client. Reasons for removal of sections will be documented in the record. Clients have the right to appeal a decision limiting access to their records to the director. Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records." This revised Bill of Rights document will be distributed to all programs by 7/26/19. The Program Director will review it with all staff and it will be incorporated into the client orientation manuals and signed by all active clients by 8/2/19. The Program Director will ensure that as a part of the regular, monthly CQI Chart Audit process, the current version of the Client Bill of Rights is being completed. |
709.53(a) LICENSURE Complete Client Record
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:
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Observations
Based on a review of seven client records, the facility failed to provide a complete client record, which is to include a work-related treatment plan in all seven client records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In-service was conducted on 7/17/2019 on the inclusion of work therapy in treatment planning. The treatment team will review this process monthly to ensure continued compliance with this matter. The inclusion of work therapy will be included during all new clinical hires orientation period. Treatment plans will continued to be reviewed by the Program Director before inclusion in the electronic medical record. |