INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 11, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gaudenzia New Destiny 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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705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential 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
Based on a physical plant inspection, the facility failed to ensure that the shared bathroom in Room 8 had a wall mirror.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
An acquisition for the purchase of a bathroom mirror was submitted on 5/17/21. The Program Director and staff will ensure that mirrors and present in all bathrooms. In order to keep in compliance with regulation 705.6(2), inspection of all bathrooms and bathroom mirrors, and all cited under regulation 705.6(2) is added to house run list conducted by staff.
Program Director will review completedd house run sheets monthly.
Additionally, the Regional Quality Assurance Manager, will conduct quarterly site visits to ensure compliance and will be documented on the quarterly CQI report. |
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 seven 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 four records reviewed.
Client #1 was admitted on November 20, 2020 and was still active the time of the inspection. Consent to release forms were signed and dated by the client on November 20, 2020 to county agencies allowing for the release of physical, mental health records, medical records, and assessments.
Client #5 was admitted on July 10, 2020 and was discharged on December 30, 2020. Consent to release forms were signed and dated by the client on July 10, 2020 to county agencies allowing for the release of physical, mental health records, medical records, and assessments.
Client #6 was admitted on September 3, 2020 and was discharged on February 4, 2021. Consent to release forms were signed and dated by the client on September 3, 2020 to county agencies allowing for the release of physical, mental health records, medical records, and assessments.
Client #7 was admitted on November 19, 2020 and was discharged on February 23, 2021. Consent to release forms were signed and dated by the client on November 19, 2020 to county agencies allowing for the release of physical, mental health records, medical records, and assessments.
These findings were discussed with facility staff during the inspection process.
This is a repeat citation from an inspection on November 6, 2020.
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Plan of Correction
The Program Director conducted a re-training with Clinical Staff, Case Manager, and Administrative Assistant on 5/17/2021 on the 5-points of consents and releases in order to be in compliance with regulation 709.28. Supervisory notes were placed in personnel file documenting awareness and understanding.
Compliance to this confidentiality regulation will be ensured by the Program Director and Clinical Supervisor during monthly CQI process. Additionally, the Regional Quality Assurance Manager will conduct quarterly audits to ensure compliance. This audit will be documented in the quarterly CQI report. |
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 a review of seven client records, the facility failed to ensure that two records reviewed included follow up information.
Client #5 was admitted on July 10, 2020 and was discharged on December 30, 2020.
Client #6 was admitted on September 3, 2020 and was discharged on February 4, 2021.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Program Director/ Clinical supervisor will review upcoming discharges via administrative staff meeting to ensure that follow-up information is updated and documented in order to comply with 709.53 regarding Follow-up information on discharged clients. This will include follow-up consent, and complete for clients who are eligible for discharge.
The administrative assistant will document the client's date of discharge, address, and other pertinent discharge information to ensure a proper follow-up can be made within 7 days following discharge.
THe Case Manager will complete all follow-up calls within 7 days of discharge and document these calls via the EHR system.
THe Program Director/Clinical Supervisor will review compliance during monthly internalCQI process.
The Quality Assurance team will conduct quarterly reviews and the Compliance team will conduct at least annual reviews of the plan of correction to ensure compliance.
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