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 September 29, 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, Gaudenzia Washington 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
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 five of seven client records reviewed.
Client #1 was admitted on August 1, 2019 and was discharged on November 1, 2019. A release of information form to a funding source, signed and dated by the client on August 1, 2019, 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 and medication records, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #2 was admitted on November 29, 2019 and was discharged on March 20, 2020. A release of information form to a funding source, signed and dated by the client on November 29, 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 and medication records, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #5 was admitted on June 25, 2020 and was active at time of inspection A release of information form to a government agency, signed and dated by the client on June 25, 2020, which allowed for the release of psychological and psychiatric evaluations, medication records, and assessment, all of which exceeds the limits established by 4 Pa. Code 255.5. Additionally, a release of information form to a funding source, signed and dated by the client on June 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 and medication records, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #6 was admitted on July 9, 2020 and was active at time of inspection. A release of information form to a government agency, signed and dated by the client on July 9, 2020, that allowed for the release assessments, which exceed the limits established by 4 Pa. Code 255.5. Additionally, a release of information form to a funding source, signed and dated by the client on July 9, 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 August 25, 2020 and was active at time of inspection. A release of information form to a funding source, signed and dated by the client on August 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, and medication records, 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
Starting October 1, 2020 all new admission completed by Program Director and or Counselor will obtain an inform consent from client limiting disclosure to the five areas according to 4 PA 255.5; (1) Whether the client is or is not in treatment.
(2) The prognosis of the client.
(3) The nature of the project.
(4) A brief description of the progress of the client.
(5) A short statement as to whether the client has relapsed into drug, or alcohol abuse and the frequency of such relapse.
Intake staff will not check any box on Gaudenzia's consent form outside of the five area identified in 4 Pa. Code 255.5.
Client audit will be conducted by Program Director on a monthly basis to ensure consent forms are completed correctly. Any discrepancies will be address with staff during regular supervision.
Program Director will review all active files by 11/20/20 to ensure that the releases are correctly documented. If releases are not correctly documented the release will be revoked and replaced with the correct release of information. |
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
The facility failed to maintain a complete client record on an individual, which is to include follow-up information, in four of seven client records reviewed.
Client #1 was admitted on August 1, 2019 and was discharged on November 1, 2019. Follow-up information was not documented in the client's record.
Client #2 was admitted on November 29, 2019 and was discharged on March 20, 2020. Follow-up information was not documented in the client's record.
Client #3 was admitted on February 19, 2020 and was discharged May 4, 2020. Follow-up information was not documented in the client's record.
Client #4 was admitted on May 18, 2020 and discharged on August 10, 2020. Follow-up information was not documented in the client's record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Washington House has implemented the following practice 10/01/2020 to document all contact/attempt to contact members following discharge. Administrator has developed a "Discharge contact data base". The Administrator will call all discharge members within seven days of discharge and record: member's name, discharge date, date contact made/or not, means of contact any comment and record information in the data base. Program Director will review the data base on a monthly bases to ensure follow-up calls are made and recorded. |
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
The facility failed to maintain a complete client record, which is to include verification that any work done by the client at the project is an integral part of their treatment and rehabilitation plan, in three of seven client records reviewed.
Client #3 was admitted on February 19, 2020 and was discharged May 4, 2020. There was documentation of work therapy being completed by the client at the facility; however, no documentation of work therapy was included on their individual treatment and rehabilitation plans.
Client #5 was admitted on June 25, 2020 and was active at time of inspection. There was documentation of work therapy being completed by the client at the facility; however, no documentation of work therapy was included on their individual treatment and rehabilitation plans.
Client #6 was admitted on July 9, 2020 and was active at time of inspection. There was documentation of work therapy being completed by the client at the facility; however, no documentation of work therapy was included on their individual treatment and rehabilitation plans.
Client #7 was admitted on August 25, 2020 and was active at time of inspection. There was documentation of work therapy being completed by the client at the facility; however, no documentation of work therapy was included on their individual treatment and rehabilitation plans.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On October 1, 2020 Clinical in-service was conducted on including work therapy to all treatment plans. Work therapy goal will be carried out throughout the member's treatment experience.
Program Director will audit files on a monthly basis to ensure that the treatment plans appropriately reflect work as an essential part of treatment. It any discrepancies with the treatment plan it will be addressed with the Counselor during regular supervision. |