INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on June 18, 2019 of Gaudeniza Outpatient by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Gaudeniza Outpatient 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:
|
Plan of Correction
|
704.11(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
|
Observations
Based on a review of the policy and procedure manual, the facility failed to follow their policy in regard to completion of the assessment of staff training needs. The Plan for Assessing Staff Training Needs policy stated, "The training plan shall be ready for implementation effective Jan. 31st of each year." The overall training plan for the project was not completed until May 16th, 2019.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The relevant Gaudenzia Policy has been revised to state that, "Program-level training needs assessments are due to the Training department by the end of January of each year. Upon receipt of the program-level annual assessments of staff training needs, the Director of Training and Education, in collaboration with the Project Director, will review the assessments in detail and develop a plan to address the training needs of the agency. The annual agency-wide training plan shall be ready for implementation no later than April 30th of each year." The Gaudenzia Director of Training and Education will ensure that this is completed within the designated timeframe each year. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
|
Observations
Based on a physical plant inspection on June 18, 2019 the facility failed to ensure that counseling session cannot be seen or heard outside of the counseling room. Room B1 had a window on the door with no covering.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Counselor for office B1 placed a window covering over office door window on 6/18/19, same day as inspection. Program Director will complete monthly walk-thru to ensure that all office windows have the necessary covering. This will be on-going. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
|
Observations
Based on the review of client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in client records, #5 and #7.
Client #5 was admitted on July 6, 2018 and was discharged on February 15, 2019. There was documentation that a fax was sent to a government agency on July 6, 2018 and July 2, 2019; however, there was no proper consent to release information form signed by the client prior to disclosure.
Client #7 was admitted on November 29, 2018 and was discharged on May 28, 2019. There was documentation that a fax was sent to a government agency on November 29 however, there was no proper consent to release information form signed by the client prior to disclosure.
The findings were discussed with facility staff during the licensing process.
|
Plan of Correction
Release forms needed will be reviewed with all staff by Program Supervisor by 8/30/19. Charts will be audited by clinical supervisor monthly during our ongoing QI process. 20% of all open charts will be reviewed for completeness to include release forms. All Discharge charts will be reviewed monthly by program supervisor and supervision will be provided to staff as needed based on results of QI. |
709.30 (1) 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.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
|
Observations
Based on a review of seven client records, the facility's client rights documentation, included in the orientation packet, failed to include all the required client rights. The facility failed to include that:
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.
Clients have the right to appeal a decision limiting access to their records to the director.
Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Continuous Quality Improvement Director has revised the Gaudenzia Client Bill of Rights to accurately reflect the DDAP 709.30 regulations regarding a client's right to inspect their own record and actions they make take in this regard. The document now states that, "The following rights are affirmed... The right to examine one's own record within the guidelines approved by the agency in accordance with Federal regulations 42 CFR, and rebut any information in their record by inserting a counter statement of clarification or correction. The agency may temporarily remove portions of the record prior to inspection if the Director determines that the information may be detrimental if presented to the client. Reasons for removal of sections will be documented in the record. Clients have the right to appeal a decision limiting access to their records to the director. Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records." This revised Bill of Rights document will be distributed to all programs by 7/26/19. The Program Director will review it with all staff and it will be incorporated into the client orientation manuals and signed by all active clients by 8/2/19. The Program Director will ensure that as a part of the regular, monthly CQI Chart Audit process, the current version of the Client Bill of Rights is being completed. |
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.
|
Observations
Based on a review of seven client records, the project failed to notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project in one of two applicable records reviewed.
Client #7 was admitted on December 28, 2018 and was administratively discharged on March 26, 2019.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
All staff will be provided with the standard letter of termination and the need of mailing the letter timely to clients will be reviewed with staff in staff meeting by 8/30/19. Program Supervisor will monitor this monthly as part of routine chart audit process. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
|
Observations
Based on a review of seven client records, the facility failed to document a comprehensive treatment and rehabilitation plan in client records # 1, # 5 and # 6.
Client #1 was admitted on March 16, 2019 and was still active at the time of the inspection. A preliminary treatment and rehabilitation plan was completed on March 12, 2019; however, no comprehensive treatment and rehabilitation plan was documented at the time of inspection.
Client #5 was admitted on July 6th, 2019 and was still active at the time of inspection. The preliminary treatment and rehabilitation plan was created on July 6, 2018; however, the comprehensive treatment and rehabilitation plan was not documented at time of inspection.
Client #6 was admitted on December 28, 2018 and was still active at the time of inspection. The preliminary treatment and rehabilitation plan was created on December 28, 2018 ; however, the comprehensive treatment and rehabilitation plan was not documented at time of inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Comprehensive treatment planning timelines will be reviewed with all staff in staff meeting by 8/30/19 by Program Supervisor. QI will be completed monthly on 20% of all charts and individual supervision will be provided to staff as needed to make sure documentation time lines are being followed. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
|
Observations
Based on a review of client records, the facility failed to document treatment and rehabilitation plan updates at least every 60 days in six out of seven records reviewed.
Client # 1 was admitted on March 16, 2019 and was still active at the time of the inspection. A treatment and rehabilitation plan was completed on March 12, 0219 and the next update was due no later than May 12, 2019; however, there was no update documented in the record at the time of the inspection.
Client # 2 was admitted on October 4, 2018 and was still active at the time of the inspection. A treatment and rehabilitation plan update was completed on April 8, 2019 and the next update was due no later than June 8, 2019; however, there was no update documented in the record at the time of the inspection.
Client # 3 was admitted on December 27, 2018 and was still active at the time of the inspection. A treatment and rehabilitation plan update was completed on March 6, 2019 and the next update was due no later than May 6, 2019; however, there was no update documented in the record until May 16, 2019.
Client # 5 was admitted on July 6, 2018 and was discharged February 15, 2019. A treatment and rehabilitation plan update was completed on July 6, 2018 and the next update was due no later than September 6, 2018; however, there was no update documented in the record at the time of the inspection.
Client # 6 was admitted on December 28, 2018 and was discharged on March 26, 2019. A treatment and rehabilitation plan update was completed on December 28th, 2018 and the next update was due no later than February 28th, 2019; however, there was no update documented in the record at the time of the inspection.
Client # 7 was admitted on November 29, 2018 and was discharged on May 28, 2019. A treatment and rehabilitation plan update was completed on February 19, 2019 and the next update was due no later than April 19, 2019; however, there was no update documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Treatment planning update timelines will be reviewed with all staff in staff meeting by 8/30/19 by Program Supervisor. QI will be completed monthly on 20% of all charts and individual supervision will be provided to staff as needed to make sure documentation time lines are being followed. |
709.93(a) 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:
|
Observations
Based on a review of client records, the facility failed to provide a complete client record for client # 5 and #6.
Client # 5 was admitted on July 6, 2018 and was discharged on February 15, 2019. The client record did not contain documentation of a discharge summary, aftercare plan or follow up.
Client # 6 was admitted on December 28. 2018 and was discharged on March 26, 2019. The client record did not contain documentation of a discharge summary, aftercare plan or follow up.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Documentation requirements, specifically for discharge summary, aftercare plan, and follow up will be reviewed with staff in individual supervision by 8/30/19 with Clinical Supervisor. QI review will be completed on all discharge charts by clinical supervisor each month and results will be reviewed with each clinician and corrections made as needed/able. |