INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 6-7, 2017 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the 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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705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a physical plant inspection on June 7, 2017 at approximately 11:00 am, the facility's kitchen freezer (located outdoors) temperature was measured at 16 degrees at the time of the inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Division Director submitted a work order to correct the issue with the freezer. The temperature issue was repaired, and on 6/30/17 the freezer temperature is reading -1 degree.
The cook will continue recording temperatures of all refrigerators and freezers twice daily on the facility temperature logs. The cook will immediately report any refrigerator temperature above 40 degrees, and any freezer recording above 0 degrees. The Program Director will also monitor through the monthly safety reporting process. |
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
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 1 of 21 client records. Additionally, 1 of 14 client records had consent to release forms that were missing the expiration date and/or witness signature.
Client #11 was admitted on 6/2/17 and was still an active client at the time of the inspection. There were consent to release forms signed and dated by the client on 6/1/17 to four different treatment providers and a government agency, but they did not include the witness signature and expiration date. Additionally, there was a consent to release form signed and dated 6/2/17 to a healthcare provider that was not specified, nor did it have a witness signature.
Client #16 was admitted on 4/21/17 and was discharged on 4/26/17. There was documentation of correspondence with a government agency on 5/25/17; however, there was no consent to release information form signed by the client prior to the disclosure of information.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Client # 11 was discharged on 6/7/17. The cited releases of information were corrected prior to the client's discharge. The Program Director has reviewed Confidentiality regulations and proper procedures for completing consents to release information with all staff members. The Program Director and Clinical Supervisor will continue supervision and training to ensure necessary releases of information are completed per licensing regulations. The Program Director and Clinical Supervisor will also monitor adherence to licensing regulations through daily/weekly chart reviews and monthly CQI/PI process. |
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.
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Observations
Based on a review of fourteen client records, each client record reviewed lacked documentation verifying written acknowledgement by clients that they had been notified of each of the client rights, including that facility staff may limit access to their records if determined to be detrimental, the right to appeal a decision limiting access to their records, and the right to request the correction of inaccurate information in the record.
These findings were reviewed with facility staff during the licensing process
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Plan of Correction
Gaudenzia will ensure that all Clients are fully informed of their rights as per DDAP regulations. Relevant sections of existing Gaudenzia, Inc. policy will be added to the client orientation materials which will be reviewed with the client at the beginning of treatment who will sign to indicate that they have received and understand all orientation materials. The Program Director will ensure that this is completed by July 30th, 2017. The regular CQI audits at each program will be utilized on a monthly basis to monitor completion of orientation sign off.
All current clients as of 6/30/17 have been notified, by the Program Director, of their client rights regarding limited access to their records, right to appeal, and right to request correction. The Program Director will secure written verification of notification by 6/30/17. |
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 provide a complete client record in 3 of 7 records.
Client # 8 was admitted on 5/28/17 and was still an active client at the time of inspection. The client record did not contain documentation of progress notes or a record of service.
Client # 19 was admitted on 10/8/16 and was discharged on 5/26/17. The client record did not contain documentation of progress notes or a record of service.
Client # 20 was admitted on 10/23/16 and was discharged on 11/28/16. The client record did not contain documentation of progress notes or a record of service.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #8 was discharged on 6/26/17. Prior to discharge, the progress notes and record of service were brought up to date and retained in the clinical chart. The Division Director and Program Director have met with the clinical team to review the standards for clinical documentation. The Division Director developed a spreadsheet to assist clinicians in completing all documentation in a timely manner, and to assist the Clinical Supervisor in chart reviews. The Program Director and Clinical Supervisor will continue ongoing supervision and monitoring of clinical documentation through daily/weekly chart reviews and monthly CQI/PI process. |