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 8, 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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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential 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.
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Observations
Based on a physical plant inspection, the facility failed to 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. A counseling session could be heard from outside an office on the outside hallway of the facility. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Sound Diffusers have been ordered for all counseling spaces throughout the site. The Clinical Director will ensure that diffusers are placed in all counseling spaces and are operational during business hours. Counseling staff will also be briefed on the use of these devices to ensure confidentiality. |
709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
Based on a review of the facilities Covid 19 policy and procedure for obtaining client signatures for consent to release forms, the policy stated "...affirmation will indicate that the individual willingly gave to Gaudenzia staff verbal consent to participate in telehealth/telephonic services, and/or verbal permission to sign treatment documents on their behalf during that time".The policy and procedure did not provide information on how the facility will attempt to get client signatures on consent to release forms. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Covid-19 Policy and Procedure is currently being revised by the Continuous Quality Assurance Department to indicate how the project will attempt to obtain signatures on consent to release forms. The Clinical Director will work with CQI to ensure that the policy is updated, staff are trained on the new procedure and the policy is implemented fully.
The site has also implemented a new internal procedure to ensure that signatures are obtained. Counseling Staff will schedule at least one face-to-face meeting with all clients for orientation. During this meeting Counseling staff will obtain the necessary signatures for consents and releases. The Clinical Director will ensure that all staff are trained on this new procedure. The Clinical Director will conduct monthly audits to ensure that signatures are obtained for consents. |
709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
Based on a physical plant inspection, the facility failed to secure hard copy client records within locked storage containers. A room that stored hard copy client records was not locked and the storage containers were not locked.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director held a staff in-service on 10/09/20 where all staff were reminded of the importance of keeping the records room door and cabinets locked. In addition, signage was placed in the records room to remind staff to keep the cabinet and door locked. The Clinical Director or designee will check the records room for compliance regularly during business hours. |
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 a review of four of seven client records, the facility failed to provide an informed and voluntary consent from the client for the disclosure of information contained in the client record.Client # 2 was admitted on May 5, 2020 and was still active at the time of the inspection. Consent to release forms in the client record did not have a valid signature or documentation of attempts to obtain client signatures.Client # 4 was admitted April 23, 2020 and was still active at the time of the inspection. There were no consent to release forms documented in the client record. Client # 5 was admitted August 1, 2019 and was discharged on December 18, 2019. There were no consent to release forms documented in the client record. Client # 6 was admitted November 29, 2019 and was discharged on January 3, 2020. There were no consent to release forms documented in the client record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The site has implemented a new internal procedure to ensure that signatures are obtained on consents and releases. Counseling Staff will schedule at least one face-to-face meeting with all clients for orientation. During this meeting Counseling staff will obtain the necessary signatures for consents and releases. If the Counselor is unable to obtain a signed release for any reason, the Counselor will complete an independent note in the record indicating their attempt.
The Clinical Director will ensure that all staff are trained on this new procedure. The Clinical Director will conduct monthly audits to ensure that signatures are obtained for consents.
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709.29 (a) LICENSURE Retention of client records
§ 709.29. Retention of client records.
(a) Client records, regardless of format, shall be readily accessible for a minimum of 4 years following the discharge of a client.
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Observations
Based on the request for two of seven client records, the facility was unable to provide records for client # 4 and 5.Client # 4 was admitted on April 23, 2020 and was still active at the time of the inspection. Records in paper format were not available when requested.Client # 5 was admitted on August 1, 2019 and was discharged on December 18, 2019. Records in paper format were not available when requested.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 10/01/2020, the site has ended the use of paper client records. All client records are now available in the electronic health record (MyAdvatar) and are maintained electronically for at least 4 years following discharge of a client.
All paper records have been properly archived and stored. These records will be maintained for at least 4 years following the discharge of a client and can be retrieved within 48 hours upon request.
The Clinical Director or designee will maintain a log of all archived records. |
709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Based on the review of the project ' s unusual incident report, the project failed to provide documentation of incidents involving death or serious injury due to trauma, suicide, medication error or unusual circumstances.An unusual incident documented in the unusual incident binder provided by the facility stated a death occurred due to an overdose on February 18, 2020 and April 1, 2020. This information was not provided to the Department.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Effective 10/13/2020 the Clinical Director will submit all unusual incident reports to the department utilizing DDAP's event reporting system. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on the review of the project ' s unusual incident reports, the project failed to provide documentation of incidents involving the presence of police, fire or ambulance personnel. An unusual incident documented in the unusual incident binder provided by the project stated the presence of police occurred on June 19, 2020 and December 6, 2019. This information was not provided to the Department.An unusual incident documented in the unusual incident binder provided by the project stated the presence of an ambulance occurred on April 10, 2020. This information was not provided to the Department.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Effective 10/13/2020 the Clinical Director will submit all unusual incident reports to the department utilizing DDAP's event reporting system. |
709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on the review of seven client records, the facility failed to provide documentation of the client being notified to the facilities criteria for admission, treatment, completion and discharge in four client records. Clients # 4, 5, 6, and 7 were missing this information.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clients are required to complete an "orientation process" at the onset of service. During this process client's are notified of the criteria for admission, treatment, completion and discharge. In addition, all clients are given a copy of the the "Client Handbook", which also includes the criteria for admission, treatment, completion and discharge. All clients are required to sign documentation of completing the orientation process.
The Clinical Director will ensure that all clients sign the "orientation sign off" in MyAdvatar during the "orientation process". The Clinical Director will complete monthly audits of client records to ensure that this process is being followed. |
709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
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Observations
Based on the review of seven client records, the facility failed to provide documentation of a client orientation to include a familiarization with the project policies in four client records. Clients # 4, 5, 6, and 7 did not have this information in their record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clients are required to complete an "orientation process" at the onset of service. During this process client's are familiarized with the site's policies. In addition, all clients are given a copy of the the "Client Handbook", which also includes site specific policies. All clients are required to sign documentation of completing the orientation process.
The Clinical Director will ensure that all clients sign the "orientation sign off" in MyAdvatar during the "orientation process". The Clinical Director will complete monthly audits of client records to ensure that this process is being followed. |
709.91(b)(2)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(ii) Hours of operation.
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Observations
Based on the review of seven client records, the facility failed to provide documentation of a client orientation to include a familiarization with the hours of operation in four client records. Clients # 4, 5, 6, and 7 did not have this documentation in their record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clients are required to complete an "orientation process" at the onset of service. During this process client's are notified of the hours of operation. In addition, all clients are given a copy of the the "Client Handbook", which also includes the hours of operation. All clients are required to sign documentation indicating completion of the orientation process.
The Clinical Director or designee will ensure that all clients sign the "orientation sign off" in MyAdvatar during the "orientation process". The Clinical Director will complete monthly audits of client records to ensure that this process is being followed. |
709.91(b)(2)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iii) Fee schedule.
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Observations
Based on the review of seven client records, the facility failed to provide documentation of a client orientation to include a familiarization with the fee schedule in four client records. Client records # 4, 5, 6, and 7 were missing this information. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clients are required to complete an "orientation process" at the onset of service. During this process client's are notified of the fee schedule. In addition, all clients are given a copy of the the "Client Handbook", which also includes the information on the fee schedule. All clients are required to sign documentation indicating completion the orientation process.
The Clinical Director or designee will ensure that all clients sign the "orientation sign off" in MyAdvatar during the "orientation process". The Clinical Director will complete monthly audits of client records to ensure that this process is being followed. |
709.91(b)(2)(iv) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iv) Services provided.
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Observations
Based on the review of seven client records, the facility failed to provide documentation of a client orientation to include a familiarization with the services provided in four client records. Client records # 4, 5, 6, and 7 did not include this information. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clients are required to complete an "orientation process" at the onset of service. During this process client's are familiarized with the services provided. In addition, all clients are given a copy of the the "Client Handbook", which also includes information on services provided. All clients are required to sign documentation indicating completion of the orientation process.
The Clinical Director or designee will ensure that all clients sign the "orientation sign off" in MyAdvatar during the "orientation process". The Clinical Director will complete monthly audits of client records to ensure that this process is 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.
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Observations
Based on the review of seven client records, the facility failed to provide documentation of treatment and rehabilitation plan updates every sixty days in three client records # 1, 4, and 7.Client # 1 was admitted on February 24, 2020 and was still active at the time of the inspection. A treatment and rehabilitation plan update occurred on March 11, 2020. Updates were due to occur on May 11 and July 11, 2020, but there was no documentation they were completed.Client # 4 was admitted on April 23, 2020 and was still active at the time of the inspection. A treatment and rehabilitation plan occurred on April 23, 2020. Updates were due to occur on June 23 and August 23, 2020, but there was no documentation they were completed.Client # 7 was admitted on January 10, 2020 and was discharged on June 18, 2020. A treatment and rehabilitation plan occurred on January 10, 2020. Updates were due to occur on March 10 and May 10, 2020, but there was no documentation they were completed.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director conducted a staff in-service on 10/09/2020 to provide technical assistance to Counseling staff regarding Treatment Plan updates and the timely completion of Treatment Plans.
The Clinical Director will conduct monthly audits of active files to ensure that Treatment Plans are updated every 60 days. The Clinical Director will review these audits with the Counseling Staff during supervision. |
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
Based on the review of seven client records, the facility failed to provide case consultations according to their policy and procedures and workflow chart provided. The workflow chart states that case consultations shall occur as step three within thirty days.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will conduct monthly audits of active files to ensure that Case Consults are Conducted in accordance with policy. The Clinical Director will review these audits with the Counseling Staff during supervision. |