INITIAL COMMENTS
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This report is a result of an on-site licensure inspection conducted on May 12, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Washington 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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705.10 (d) (8) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(8) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the facility's fire drill log, the facility failed to set off a fire alarm or smoke detector during each fire drill.
The findings include:
The facility's fire drill log was reviewed on May 12, 2014, for the period covering July 2013 to May 4, 2014. The facility failed to set off a fire alarm or smoke detector during each fire drill.
The Administrative Coordinator and Facility Director confirmed the findings.
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Plan of Correction
Program Director will assure that the fire drill is activated utilizing the alarm system as required in regulation 705.10 (b). The fire drill log will be reviewed, dated and signed by the program Director at the end of each month to assure compliance and adherence to regulation 705.10. Program Director will assure full and on-going compliance through providing monthly oversight of fire drill procedures and activation. The facility will be in full compliance preceding the fire drill scheduled for 5-27-14.
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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 to release client information form or failed to obtain an informed and voluntary consent to release client information form to include the specific information disclosed, in three of four client records reviewed.
The findings include:
Four client records were reviewed for documentation of informed and voluntary consent to release client information forms on May 12, 2014. The facility failed to obtain an informed and voluntary consent to release client information form or failed to obtain an informed and voluntary consent to release client information form to include the specific information disclosed in client records # 1, 3 and 4.
Client # 1 was admitted to the program on 9/9/13 and was still an active client as of 5/12/14. The record contained a consent to release client information form for a government agency that was signed by the client on 9/9/13. The facility failed to document the specific information disclosed as the consent form permitted for the release of information, "pertaining to treatment process."
Client # 3 was admitted to the program on 3/3/14 and was still an active client as of 5/12/14. Per progress note documented on 5/2/14, the facility released client information to an outside agency. The facility failed to obtain an informed and voluntary consent to release information form from client # 3 for the outside agency.
Client # 4 was admitted to the program on 3/12/14 and was still an active client as of 5/12/14. Client # 4 signed a consent to release client information form on 3/12/14 for a government agency. The facility failed to document the specific information disclosed on the consent to release client information form. Client # 4 signed another consent to release client information form that failed to document the specific information disclosed as the consent form permitted for the release of information, "pertaining to treatment process."
The findings were reviewed with the Facility Director and clinical supervisor.
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Plan of Correction
Program Director met with employees on 5-22-14 for documented supervision to review citation 709.28. Employees were provided direct supervision and review of (28 Pa. Code 709.28- Confidentiality). Corrections will be made in the following records; Client 1, 3 & 4 will have correct consent forms completed identifying specific information to be released as identified in (28 Pa. Code 709.28 Confidentiality).
Client #1 consent form will be corrected on 5-23-14, identifying specific information to be disclosed.
Client #3 will be corrected on 5-23-14, consent to release information will be completed for the outside agency.
Client #4, consent form will be completed on 5-23-14 identifying specific information to be disclosed. The clinical supervisor will conduct monthly chart reviews to assure on-going compliance with regulation 709.28. The clinical supervisor will assure on-going compliance with (28 Pa. Code 709.28 Confidentiality) through conducting documented supervisions and monthly chart audits. The facility will be in full compliance as of 5-23-14.
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709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation in one of four records reviewed.
The findings include:
Four client records requiring documentation of a psychosocial evaluation were reviewed on May 12, 2014. The facility failed to document a psychosocial evaluation for client record # 1.
Client # 1 was admitted to the program on 9/9/13 and was still an active client as of 5/12/14. The facility failed to document a psychosocial evaluation in client record # 1 as of 5/12/14.
The Facility Director confirmed the findings.
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Plan of Correction
Client#1 Psychosocial Assessment has been filed in the chart #1 on 5-22-13. The clinical supervisor will assure on-going compliance with Pa Code 709.51(b)(6) through on-going conducting monthly chart audits and review. Clinical supervisor will complete monthly Continued Quality Improvement audits and record compliance as required assuring that all psychosocial evaluations are completed and filed in client charts. Clinical supervisor will provide a copy of the monthly clinical audits to the program Director monthly for review. Clinical supervisor will conduct monthly clinical supervision and review compliance with Pa Code 709.51(b)(6) to assure on-going compliance. Correction to Client #1 records was completed on 5-22-14. The facility will be in full and on-going compliance as of 5-22-14. |