INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on June 17, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Inc., Pottsville 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 and a plan of correction is due on July 21, 2010.
|
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. The consent shall be in writing and include, but not be limited to:
|
Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client prior to the disclosure of information in one of six client records.
The findings include:
Six client records were reviewed on June 17, 2010. Six of those client records were required to include an informed and voluntary consent from the client prior to the disclosure of information. Record #5 had documentation of a fax sent to the county adult probation office but there was no documentation of a consent form signed by the client.
Client #5 was admitted on 12/23/2009. A letter was sent to the Adult Probation Office via a fax which was documented on 4/20/2010. There was not a consent form allowing for the disclosure of information to the Adult Probation Office in client record #5.
|
Plan of Correction
Informed and Voluntary written consent will be obtained from clients prior to facailty staff disclosing information. All copies of consents to disclose information will be in the client record. Clinical supervisor will review the confidentiality regulations with all staff in a meeting. At this time staff will sign off that they are aware of this regulation. To further insure compliance Clinical Supervisor and Division Director will review client records on aq monthly basis. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
|
Observations
Based on a review of the fire drill record log and an interview with the facility director, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings include:
The fire drill record log was reviewed on June 17, 2010. The log was reviewed from July 2009 to May 2010. During each month a fire drill was conducted, the facility did not specify which exit was used during the fire drill but instead indicated that "ALL" exits had been used. The facility has only two exits, and the inspector could not determine which exit was specifically being used based on the documentation provided. When asked the clinical supervisor and facility director stated that they only used the front exit and did not use the fire escape because of the difficulty in getting the fire escape ladder to go back up.
|
Plan of Correction
Monthly fire drills will be conducted at the facility and alternate exit routes will be prepared to be used during fire drills. The fire escape will be scheduled as a alternate exit route when conducting fire drills. Division Director will ensure that arrangements are made to meet this requirement. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
|
Observations
Based on a review of client records, the facility failed to document treatment plans to include the type and frequency of treatment and rehabilitation services in three of six client records.
Findings:
The facility's policy titled "PROCEDURE FOR INDIVIDUAL TREATMENT & REHABILITATION PLAN" states:
" Included in the action plan will be a statement of the type (individual / group / family therapy, health education, etc.) and frequency (daily, 2-3 x weekly, once, ongoing, etc.) of service in which the client will be involved. "
Six client records were reviewed on June 17, 2010. Treatment plans with proposed types of supportive services were required in six client records. The facility did not document treatment plans to include the type and frequency of treatment and rehabilitation services in records # 1,3, and 6.
|
Plan of Correction
All treatment plans for clients will document the type and frequency of service. Clinical Supervisor will review in a staff meeting that all treatment plans must include type and frequency of treatment and rehabilition services.All staff will sign a statement this regulation was reviewed. Division Director and Clinical Supervisor will review all files monthly to ensure compliance with this regulation. |