INITIAL COMMENTS
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This report is a result of an on-site licensure inspection conducted on November 9 - 10, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia 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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in two out of ten client records reviewed.
The findings include:
4 Pa. Code 255.5 states:
Information released to judges, probation or parole officers, insurance company, health or hospital plan or governmental officials, pursuant to paragraphs (1), (2), (4),(7), (8) or subsection (a) of this section, is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following.
(1) Whether the client is or is not in treatment.
(2) Client's prognosis.
(3) The nature of the project.
(4) A brief description of the client's progress.
(5) A short statement as to whether the client has relapsed
Ten client records were reviewed on November 9 - 10, 2015, to ensure that the facility obtained an informed and voluntary consent from the client for the disclosure of information. The facility failed to obtain and comply with an informed and voluntary consent in client records, # 4 and 6.
Client # 4 was admitted to the facility on August 28, 2015. The facility failed to obtain and comply with a valid consent to release from client # 4. On September 9, 2015, client # 4 signed a general consent to release to a probation officer which documented, " To share general and specific information about my treatment including, but not limited to housing issues."
Client # 6 was admitted to the facility on September 21, 2015. The facility failed to obtain a consent to release from client # 6 for the release of information to a governmental entity. The facility documented in progress notes and other clinical documents that contact was made with client # 6's probation officer or FIR worker.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Gaudenzia Together House Program will obtain an informed and voluntary consent from the client for the disclosure of specific information disclosed in the chart.
On December 11,2015 a Record-Keeping training will be facilitated to review the Confidentiality Request to Release Information Form and DOH Policy 709.28(c)and PA Code 255.5. Projects and Coordinating Bodies: Disclosure of Client-Oriented Information.
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:
Division Director
Together House Program Director
Together House Supervisors
Timeframe for Completion: November 24, 2015
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709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in two administratively discharged records.
The findings include:
Two administrative discharged client records were reviewed on November 9 - 10, 2015. The facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in client records, # 7 and 9.
Client # 7 was admitted to the facility on September 14, 2015 and administratively discharged on October 13, 2015. The facility failed to notify client # 7 in writing, of a decision to involuntarily terminate the client's treatment at the project as of the date of the licensing inspection.
Client # 9 was admitted to the facility on June 29, 2014 and administratively discharged on August 17, 2015. The facility failed to notify client # 9 in writing, of a decision to involuntarily terminate the client's treatment at the project as of the date of the licensing inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Gaudenzia Together House Program will notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project.
On December 11, 2015 a Record-Keeping training will be facilitated to review the Notification of Termination DOH DDAP Policy 709.33(a).
All involuntary terminations will be reviewed and monitored by the program director, or their designee during monthly Continuous Quality Improvement (CQI) meetings to ensure compliance.
Persons Responsible:
Division Director
Together House Program Director
Together House Supervisors
Timeframe for Completion: November 24, 2015
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709.53(a) LICENSURE Complete Client Record
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:
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Observations
Based on a review of client records, the facility failed to document a complete client record in six out of ten client records reviewed.
The findings include:
Ten client records were reviewed on November 9 - 10, 2015. The facility failed to document a complete client record that included a record of services provided and documentation that work done by the client is an integral part of the treatment and rehabilitation plan in client records, # 1, 2, 3, 6, 7 and 8.
Client # 1 was admitted to the facility on September 17, 2015. The facility failed to document a complete record which included documentation that work done by client # 1 is an integral part of the treatment and rehabilitation plan.
Client # 2 was admitted to the facility on August 28, 2015. The facility failed to document a complete record which included a record of services provided and documentation that work done by client # 2 is an integral part of the treatment and rehabilitation plan.
Client # 3 was admitted to the facility on September 18, 2015. The facility failed to document a complete record which included documentation that work done by client # 3 is an integral part of the treatment and rehabilitation plan.
Client # 6 was admitted to the facility on September 21, 2015. The facility failed to document a complete record of services provided to client # 6, as of the date of the licensing inspection.
Client # 7 was admitted to the facility on September 14, 2015 and discharged on October 13, 2015. The facility failed to document a complete record which included documentation that work done by client # 7 was an integral part of the treatment and rehabilitation plan for client # 7's duration of treatment.
Client # 8 was admitted to the facility on July 10, 2015 and discharged on August 11, 2015. The facility failed to document a complete record of services provided to client # 8 for the duration of treatment.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
A record-keeping training will be facilitated on November 11, 2015 to include the Record of Service and any work done by the client to be an integral part of the treatment and rehabilitation plan as required by the Division of Drug and Alcohol Licensure per DOH Policy 709.53(a): Complete Client Record.
All treatment planning documentation will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings by the Program Director and Clinical Supervisor.
Persons Responsible:
Division Director
Together House Program Director and Clinical Supervisor
Timeframe for Completion: November 24, 2015
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709.17(a)(1) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(1) Failure to comply with a directive issued by the Department.
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Observations
Based on a review of administrative documentation, the facility failed to implement policies and procedures for the reporting of unusual incidents.
The findings include:
As per the directive within Chapter 709 Subchapter C enacted on 10/18/2014, the facility was required to develop and implement policies and procedures for the reporting of unusual incidents.
Based on a review of internal incident reports, the facility failed to report incidents within 3 days per regulation from the time period of July 2015 until November 2015 for incidents involving:
1.Physical or sexual assault by staff or a client.
2.Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
3.Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence that results in the closure of a facility for more than 1 day.
4.Event at the facility requiring the presence of police, fire or ambulance personnel.
5.Outbreak of a contagious disease requiring CDC notification.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
A record-keeping training will be facilitated on December 11, 2015 to include reporting of Unusual Incidents as required by the Division of Drug and Alcohol Licensure per DOH Policy 709.17(a)(1): Refusal or Revocation of License.
All DDAP Unusual Incident Reports will be reviewed and monitored daily by the Program Director and Clinical Supervisors during Morning Communication Meetings and reported at monthly during Continuous Quality Improvement (CQI) meetings.
Persons Responsible:
Division Director
Together House Program Director and Clinical Supervisors
Timeframe for Completion: December 11, 2015
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