INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, a physical plant inspection was conducted on October 28, 2020 and a client record review was conducted on March 1, 2016 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, Gratitude 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:
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Plan of Correction
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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 one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information with the specific information disclosed to not exceed pa code 255.5 (b).
Client # 1 was admitted on December 9, 2020 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information signed and dated January 18, 2021 to a probation officer allowed for the release of employment information, UDS, and mental health information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor revised consent to include all necessary disclosures. Clinical Supervisor, Lead Counselor and Executive Director will maintain spot check monthly charts to ensure proper completion, to maintain guidelines of 42 CFR, beginning immediately. Staff members will also receive training on Pa code 255.5, by clinical director, by April 30, 2021.The completion of this training will be logged in the monthly supervision document. Staff members who directly have consents signed by clients will receive training in our online training platform on the revision and completion of consents by 4/30/2021. Completion of training will be verified monthly by clinical supervisor in individual supervision. This will be documented on the CARF standardized Individual Supervision form, monthly. |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based on one of three applicable client records reviewed, the facility failed to provide a complete client record to include a discharge summary.
Client # 6 was admitted on August 20, 2020 and was discharged on November 11, 2020. There was not a discharge summary documented in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will re-train staff on the importance of aftercare form completion, to ensure compliance. There will be a new form implemented in our EMR system that is all-inclusive to all aspects of clients discharge in one document. This includes the discharge summary and discharge plan, including dates and times of outpatient appointments. This is to ensure more timely documentation of the discharge summary and plan. Counselors will receive training on this new document by 4/30/2021. The new document (called the discharge management form) will be rolled out April 19th 2021. Clinical supervisor will then complete chart audits on closed clients within 7 days of client discharge. If non- compliance continues with a counselor, this will be addressed in individual supervision and a plan of action will be made. This will take place immediately. |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on three of three applicable client records reviewed, the facility failed to provide a complete client record to include follow-up information.
Client # 5 was admitted on August 17, 2020 and was discharged on September 3, 2020. There was not follow-up information documented in the client record.
Client # 6 was admitted on August 20, 2020 and was discharged on November 11, 2020. There was not follow-up information documented in the client record.
Client # 7 was admitted on November 3, 2020 and was discharged on December 22, 2020. There was not follow-up information documented in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor and Executive Director will monitor monthly closed charts monthly to ensure aftercare calls are being completed. Executive Director reviewed aftercare call policy with administrative assistant on 3/30/21. |