INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, 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, conducted on October 6, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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, Guadenzia Together 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) 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
The project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one of seven client records reviewed.
Client #2 was admitted on July 2, 2020 and was discharged on August 18, 2020. There was evidence of the project billing for services; however, there was no documentation of an informed and voluntary consent form for the funding source in the client record prior to the disclosures.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Together House Program will obtain an informed and voluntary consent from the client for the disclosure of specific information disclosed in the charts during admission. We will review all other current open charts and obtain an informed and voluntary consent form for them as needed. This has been in effect since July 17, 2019 and charts will be reviewed on a monthly basis during CQI.
On November 13, 2020 a Record-Keeping training will be facilitated to review the 4 PA Code 255.5 Confidentiality Request to Release Information Form and DOH Policy 709.28 (c)(1).
All Consent to Release Information Forms will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings and to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible:
Deputy Director
Program Director
Program Supervisor
Timeframe for Completion: November 13, 2020 |
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
The project failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in four of seven client records reviewed.
Client #1 was admitted on January 13, 2020 and was discharged on February 7, 2020. Release of information forms to a funding source and a probation agency, both signed and dated by the client on January 13, 2020, that allowed for the release of psychological and psychiatric evaluations, treatment plans, case consults, mental health records, physical and medical records, discharge summary, progress notes, medication records and assessments, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #3 was admitted on August 15, 2020 and was active at the time of the inspection. A release of information form to a funding source, signed and dated by the client on July 17, 2020, that allowed for the release of psychological and psychiatric evaluations, treatment plans, case consults, mental health records, physical and medical records, discharge summary, progress notes, medication records and assessments, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #5 was admitted on June 16, 2020 and was active at the time of the inspection. A release of information form to a funding source, signed and dated by the client on June 16, 2020, that allowed for the release of psychological and psychiatric evaluations, treatment plans, case consults, mental health records, physical and medical records, discharge summary, progress notes, medication records and assessments, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #7 was admitted on April 20, 2020 and was discharged on June 12, 2020. A release of information form to a funding source, signed and dated by the client on April 25, 2020, that allowed for the release of psychological and psychiatric evaluations, treatment plans, case consults, mental health records, physical and medical records, discharge summary, progress notes, medication records and assessments, all of which exceeds the limits established by 4 Pa. Code 255.5.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Together House Program will obtain an informed and voluntary consent from the client for the disclosure of specific information disclosed in the charts during admission.
We will review all current non compliant open charts and obtain a current informed and voluntary consent form for them as needed. This has been in effect since October 6, 2020 and charts will be reviewed on a monthly basis during CQI.
On November 13, 2020 a Record-Keeping training will be facilitated to review the 4 PA Code 255.5 Confidentiality Request to Release Information Form and DOH Policy 709.28 (c)(1).
All Consent to Release Information Forms will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings and to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible:
Deputy Director
Program Director
Program Supervisor
Timeframe for Completion: November 13, 2020 |
709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
The project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the date, event or condition upon which the consent will expire in two of seven client records reviewed.
Client #4 was admitted on August 26, 2020 and was discharged on September 25, 2020. A release of information form to a funding source, signed and dated by the client on August 26, 2020, did not document the date, event or condition upon which the consent would expire.
Client #5 was admitted on June 16, 2020 and was active at the time of the inspection. Release of information forms to a funding source and a case manager, both signed and dated by the client on June 16, 2020, did not document the date, event or condition upon which the consent would expire.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Together House Program will obtain an informed and voluntary consent from the client for the disclosure of specific information disclosed in the charts during admission. This will be completed for all disclosure of information for outside entities and will include the date of the consent expiration.
We will review all other current non compliant open charts and obtain an informed and voluntary consent form for them per policy 709.28, as needed. This has been in effect since October 6, 2020 and charts will be reviewed on a monthly basis during CQI.
On November 13, 2020 a Record-Keeping training will be facilitated to review the 4 PA Code 255.5 Confidentiality Request to Release Information Form and DOH Policy 709.28 (c)(1).
All Consent to Release Information Forms will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings and to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible:
Deputy Director
Program Director
Program Supervisor
Timeframe for Completion: November 13, 2020
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709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
The project failed to ensure that treatment and rehabilitation plans were reviewed and updated at least every 30-days in two of seven client records reviewed.
Client #2 was admitted on July 2, 2020 and was discharged on August 18, 2020. A treatment plan update was completed on July 4, 2020 and the next update was due no later than August 4, 2020; however, there was no update documented in the record prior to discharge.
Client #5 was admitted on June 16, 2020 and was active at the time of the inspection. A treatment plan update was completed on July 20, 2020 and the next update was due no later than August 20, 2020; however, the update was not documented until September 8, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Gaudenzia Together House Program will review and update treatment plans within the regulatory guidelines as outlined in 709.52 (b) Treatment and Rehabilitation Services. The long term member updated plan will be every 30 days; short term rehabilitation updated at least every 15 days.
On November 13, 2020 a Record-Keeping training will be facilitated to review the 709.52: Treatment and Rehabilitation services.
All of the members who are discharged will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings and to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible:
Division Director
Together House Program Director
Together House Supervisor
Timeframe for Completion: November 13, 2020
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709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
The project failed to assure that counseling services were provided to the client according to the individual treatment and rehabilitation plan in five of seven client records reviewed.
Client #2 was admitted on July 2, 2020 and was discharged on August 18, 2020. The comprehensive treatment plan, completed on July 4, 2020, indicated that the client was to receive individual counseling sessions weekly; however, there were no documented individual counseling sessions for the weeks of July 12 2020 through July 18, 2020, July 19, 2020 through July 25, 2020, August 2, 2020 through August 8, 2020 and August 9, 2020 through August 15, 2020.
Client #3 was admitted on August 15, 2020 and was active at the time of the inspection. The comprehensive treatment plan, completed on August 19, 2020, indicated that the client was to receive individual counseling sessions weekly; however, there were no documented individual counseling sessions for the weeks of August 30, 2020 through September 5, 2020, September 6, 2020 through September 12, 2020, September 20, 2020 through September 26, 2020 and September 27, 2020 through October 2, 2020.
Client #4 was admitted on August 26, 2020 and was discharged on September 25, 2020. The comprehensive treatment plan, completed on August 31, 2020, indicated that the client was to receive individual counseling sessions weekly; however, there were no documented individual counseling sessions for the weeks of September 6, 2020 through September 12, 2020, September 13, 2020 through September 19, 2020 and September 20, 2020 through September 25, 2020.
Client #5 was admitted on June 16, 2020 and was active at the time of the inspection. The comprehensive treatment plan, completed on June 17, 2020, indicated that the client was to receive individual counseling sessions weekly; however, there were no documented individual counseling sessions for the weeks of September 13, 2020 through September 19, 2020 and September 20, 2020 through September 26, 2020.
Client #7 was admitted on April 20, 2020 and was discharged on June 12, 2020. The comprehensive treatment plan, completed on April 28, 2020, indicated that the client was to receive individual counseling sessions weekly; however, there were no documented individual counseling sessions for the weeks of May 3, 2020 through May 9, 2020, May 24, 2020 through May 30, 2020, May 31, 2020 through June 6, 2020 and June 7, 2020 through June 12, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Gaudenzia Together House Program will review and update treatment plans within the regulatory guidelines as outlined in 709.52 (c) Treatment and Rehabilitation Services. The long term member updated plan will be every 30 days; short term rehabilitation updated at least every 15 days.
On November 13, 2020 a Record-Keeping training will be facilitated to review the 709.52: Treatment and Rehabilitation services to assure that counseling services are provided to the client according to the individual treatment and rehabilitation plan.
All of the members who are discharged will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings and to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible:
Division Director
Together House Program Director
Together House Supervisor
Timeframe for Completion: November 13, 2020
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