INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 19, 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 Kindred 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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709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of seven client records, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in client records # 1, 3, 4, and 7.
Client #1 was admitted on 8/29/16 and was discharged on 2/3/17. A consent to release information form was signed and dated on 10/31/16 to a law enforcement agency, which allowed for the release of the client's criminal charges, violation of probation, and questions in regards to illegal weapons.
Client #3 was admitted on 10/6/16 and was discharged on 5/3/17. A consent to release information form was signed and dated on 10/7/16 to the client's probation officer, which allowed for the release of the client's court dates, criminal history, and legal expectations/requirements.
Client #4 was admitted on 1/9/17 and was discharged on 6/8/17. A consent to release information form was signed and dated on 2/24/17 to a government agency, which allowed for the release of the client's psychiatric evaluation & recommendation and drug screens.
Client #7 was admitted on 3/13/17 and was an active client at time of inspection. A consent to release information form was signed and dated on 3/13/17 to the client's probation officer, which allowed for the release of the client's court dates, history, fines and length of probation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will give the staff information on properly filling out releases correctly according to Pa.Code 255.5. The Program Director will then conduct an in-service training to all of the staff on completing consent/release forms of information on not exceeding the 5 areas according to Pa. Code 255.5. All staff completing consents/released with give them to the The Program Director to be viewed for compliance before being filed in clinical files |
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 facility's unusual incident reports on June 19, 2017, the facility failed to notify the Department within 3 business days following the unusual incident below, which were discovered during the licensing process.
The incident date and reason is:
April 21, 2017 - Police presence requested
These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
The Program Director will conduct an in-service training on the DDAP Reporting of Unusual Incidents. The Program Director reviews and signs off on all incident reports, and will determine according to the Licensing Alert 5-97 if a DDAP Unusual Incident Report needs to be done, and assure that it is completed. |