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 23, 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, Inc. 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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705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection conducted on September 23, 2020, the facility failed to ensure that hot water temperature does not exceed 120 degrees Fahrenheit. The hot water temperature in the bathroom located at the end of the hall, near the storage rooms, was tested and read 129 degrees Fahrenheit.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 9/23/20 the Director submitted a work order to the maintenance department to evaluate and adjust the water temperature for the bathroom. The bathroom was placed in "out of order" status until the repairs were completed. The water temperature has been adjusted and the bathroom is now fixed effective 10/26/20. |
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 document an informed and voluntary consent to release information form from the client for the disclosure of information contained in the client record in one of seven client records reviewed.
Client #1 was admitted on July 16, 2019 and was discharged October 10, 2019. An informed and voluntary consent form for the funding source was not documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A staff in-service will be conducted on 10/28/20 during the Clinical Team Meeting to address and update the Clinical Team on the proper documentation and use of the "Release of Information" form. The Clinical Supervisor will monitor the proper use of the "Release of Information" through monthly chart audits and will address discrepancies with staff during monthly supervision. In addition, the CQI Manager will conduct quarterly chart audits to monitor the use of the "Release of Information" form and will report findings to the Program Director on a quarterly basis. |
709.28 (c) (5) 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:
(5) Dated signature of witness.
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Observations
The project failed to document a dated witness signature on an informed and voluntary consent to release information form from the client for the disclosure of information contained in the client record in one of seven client records reviewed.
Client #6 was admitted on December 13, 2019 and was discharged March 5, 2020. A dated witness signature was not documented on three separate consent to release information forms, all signed by the client on January 30, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A staff in-service will be conducted on 10/28/20 during the Clinical Team Meeting to address and update the Clinical Team on the proper documentation and use of the "Release of Information" form, including witnessing the document. The Clinical Supervisor will monitor the proper use of the "Release of Information", including witnessing the document, through monthly chart audits and will address discrepancies with staff during monthly supervision. In addition, the CQI Manager will conduct quarterly chart audits to monitor the use of the "Release of Information" form and will report findings to the Program Director on a quarterly basis. |
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 document on an informed and voluntary consent to release form the date, event, or condition upon which the consent form would expire in one of seven client records reviewed.
Client #6 was admitted on December 13, 2019 and was discharged March 5, 2020. A date, event or condition of expiration was not documented on three separate informed and voluntary consent forms, all signed by the client on January 30, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A staff in-service will be conducted on 10/28/20 during the Clinical Team Meeting to address and update the Clinical Team on the proper documentation and use of the "Release of Information" form, including the documentation of the condition in which the consent form will expire. The Clinical Supervisor will monitor the proper use of the "Release of Information" through monthly chart audits and will address discrepancies with staff during monthly supervision. In addition, the CQI Manager will conduct quarterly chart audits to monitor the use of the "Release of Information" form and will report findings to the Program Director on a quarterly basis. |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
The project failed to document in the client record written acknowledgement that the client had been informed that the project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client and that reasons for removing sections shall be documented in the record in three of seven records reviewed.
Client #1 was admitted on July 16, 2019 and was discharged October 10, 2019.
Client #2 was admitted on July 24, 2019 and was discharged June 15, 2020.
Client #5 was admitted on August 21, 2019 and was discharged December 2, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Gaudenzia maintains a "Client Rights" policy that indicates that clients may request to review their records and that the facility may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client and that reasons for removing sections shall be documented in the record. All clients are presented the "client rights" policy at admission and receipt of the policy is documented in the client record. In addition the "client rights" policy is also made available to all clients as part of the client handbook which is distributed during "orientation" all clients acknowledge receipt of the handbook by way of the "orientation sign off" document that is maintained in the record. All clinical team members will be updated on this policy and proper documentation during an in-service on 10/28/20. The Clinical Supervisor will monitor this documentation during monthly audits of the client records and will address discrepancies with staff during regular supervisions. In addition, the CQI Manager will monitor the use of the "client rights" and "orientation sign off" documents during quarterly record audits and will report any discrepancies to the program director on a quarterly basis. |
709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
The project failed to document in the client record written acknowledgement that the client had been informed that clients have the right to appeal a decision limiting access to their records in three of seven records reviewed.
Client #1 was admitted on July 16, 2019 and was discharged October 10, 2019.
Client #2 was admitted on July 24, 2019 and was discharged June 15, 2020.
Client #5 was admitted on August 21, 2019 and was discharged December 2, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Gaudenzia maintains a "Client Rights" policy that indicates that the client has the right to appeal a decision limiting access to their records. All clients are presented the "client rights" policy at admission and receipt of the policy is documented in the client record. In addition the "client rights" policy is also made available to all clients as part of the client handbook which is distributed during "orientation" all clients acknowledge receipt of the handbook by way of the "orientation sign off" document that is maintained in the record. All clinical team members will be updated on this policy and proper documentation during an in-service on 10/28/20. The Clinical Supervisor will monitor this documentation during monthly audits of the client records and will address discrepancies with staff during regular supervisions. In addition, the CQI Manager will monitor the use of the "client rights" and "orientation sign off" documents during quarterly record audits and will report any discrepancies to the program director on a quarterly basis. |
709.30 (5) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
The project failed to document in the client record written acknowledgement that the client had been informed that clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records, in three of seven client records reviewed.
Client #1 was admitted on July 16, 2019 and was discharged October 10, 2019.
Client #2 was admitted on July 24, 2019 and was discharged June 15, 2020.
Client #5 was admitted on August 21, 2019 and was discharged December 2, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Gaudenzia maintains a "Client Rights" policy that indicates that clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records. All clients are presented the "client rights" policy at admission and receipt of the policy is documented in the client record. In addition the "client rights" policy is also made available to all clients as part of the client handbook which is distributed during "orientation" all clients acknowledge receipt of the handbook by way of the "orientation sign off" document that is maintained in the record. All clinical team members will be updated on this policy and proper documentation during an in-service on 10/28/20. The Clinical Supervisor will monitor this documentation during monthly audits of the client records and will address discrepancies with staff during regular supervisions. In addition, the CQI Manager will monitor the use of the "client rights" and "orientation sign off" documents during quarterly record audits and will report any discrepancies to the program director on a quarterly basis.
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709.93(a)(8) LICENSURE Client records
709.93. 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:
(8) Case consultation notes.
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Observations
The facility failed to ensure that there was a complete client record, which included case consultation notes, in two of seven records reviewed.
Client #1 was admitted on July 16, 2019 and was discharged October 10, 2019. There were no case consultation notes documented in the client's record prior to discharge.
Client #3 was admitted on May 4, 2020 and was discharged September 21, 2020. There were no case consultation notes documented in the client's record prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility's policy indicates that documentation of Case Consultations shall be maintained in the client's electronic record. All Clinical Staff will be updated on this policy and the proper documentation of Case Consultations during an in-service on 10/28/20. The Clinical Supervisor will monitor the documentation of Case Consultations during monthly chart audits and will address discrepancies with staff during regular supervision. In addition, the CQI Manager will conduct quarterly chart audits which will include the documentation of Case Consultations. Discrepancies will be share with the program director on a quarterly basis. |
709.93(a)(11) LICENSURE Client records
709.93. 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 project failed to ensure that there was a complete client record, which included follow-up information in two of five applicable client records reviewed.
Client #1 was admitted on July 16, 2019 and was discharged October 10, 2019. There was no follow-up information documented in the client's record at the time of the inspection.
Client #2 was admitted on July 24, 2019 and was discharged June 15, 2020. There was no follow-up information documented in the client's record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility maintains a current policy that staff will conduct a follow up with all clients 30 days after discharge and that the facility will maintain documentation of its efforts to follow up with all clients. The Director or designee shall maintain a log of all discharges that will include all follow up activities for each discharged client. This log will be monitored by the Director on a monthly basis to ensure completion. |