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 October 28, 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 Broad Street 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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705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
The facility failed to ensure that hot water temperatures did not exceed 120 degrees Fahrenheit. The male bathroom on the third floor was tested with a thermometer and the reading indicated the temperature to be 128 degrees Fahrenheit.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Maintenance adjusted the hot water tank to reflect the appropriate temperature. Maintenance will conduct regulatory checks to ensure the temperature is adequate. |
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
The project failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in seven of seven client records reviewed.
Client #1 was admitted on August 25, 2020 and was active at time of inspection. A release of information form to a funding source, signed and dated by the client on August 25, 2020, that allowed for the release of psychological and psychiatric evaluations, treatment plans, case consults, mental health records, physical and medical records, discharge summary, progress notes, medication records and assessments, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #2 was admitted on August 20, 2020 and was active at time of inspection. A release of information form to a funding source, signed and dated by the client on August 20, 2020, that allowed for the release of psychological and psychiatric evaluations, treatment plans, case consults, mental health records, physical and medical records, discharge summary, progress notes, medication records and assessments, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #3 was admitted on July 29, 2020 and was active at time of inspection. A release of information form to a funding source, signed and dated by the client on July 29, 2020, that allowed for the release of psychological and psychiatric evaluations, treatment plans, case consults, mental health records, physical and medical records, discharge summary, progress notes, medication records and assessments, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #4 was admitted on August 19, 2020 and was discharged October 23, 2020. A release of information form to a funding source, signed and dated by the client on August 19, 2020, that allowed for the release of psychological and psychiatric evaluations, treatment plans, case consults, mental health records, physical and medical records, discharge summary, progress notes, medication records and assessments, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #5 was admitted on July 28, 2020 and was discharged September 1, 2020. A release of information form to a funding source, signed and dated by the client on July 28, 2020, that allowed for the release of psychological and psychiatric evaluations, treatment plans, case consults, mental health records, physical and medical records, discharge summary, progress notes, medication records and assessments, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #6 was admitted on May 6, 2020 and was discharged July 28, 2020. A release of information form to a funding source signed and dated by the client on August 19, 2020 that allowed for the release of psychological and psychiatric evaluations, treatment plans, case consults, mental health records, physical and medical records, discharge summary, progress notes, medication records and assessments, all of which exceeds the limits established by 4 Pa. Code 255.5. Additionally, a release of information form to a probation agency, signed and dated by the client on August 19, 2020, that allowed for the release of psychological and psychiatric evaluations, treatment plans, case consults, mental health records, physical and medical records, discharge summary, progress notes, medication records and assessments.
Client #7 was admitted on March 4, 2020 and was discharged May 22, 2020. A release of information form to a funding source, signed and dated by the client on March 4, 2020, that allowed for the release of psychological and psychiatric evaluations, treatment plans, case consults, mental health records, physical and medical records, discharge summary, progress notes, medication records and assessments, all of which exceeds the limits established by 4 Pa. Code 255.5.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All releases of information will be kept within the limits established by 4 PA Code 255.5 (b). All clinical staff will be trained by the Facility Director in an in-service training on 12/10/2020 regarding these limits as well as the correct use of the release of information form in the electronic health record. The Clinical Supervisor will conduct at least weekly audits of charts in order to ensure compliance. The Quality Assurance department will conduct at least quarterly reviews of the program in order to ensure compliance. The findings of these audits will be reviewed in regular CQI meetings following the audits. The Compliance department will conduct at least annual reviews to ensure compliance with corrective action plans. |
709.34 (c) (1) 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:
(1) Physical or sexual assault by staff or a client.
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Observations
The project failed to file a written unusual incident report with the Department within 3 business days following an unusual incident involving physical or sexual assault by staff or a client.
On January 26, 2020, there was a physical altercation between clients at the facility. There was no documentation that an unusual incident was filed with the department.
On March 26, 2020, there was a physical altercation between clients at the facility. There was no documentation that an unusual incident was filed with the department.
On August 9, 2020, there was a physical altercation between a client and staff member at the facility. There was no documentation that an unusual incident was filed with the department.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A written unusual incident report will be filed with the Department within 3 business days following an unusual incident involving a death or serious injury due to trauma, suicide, medication error or unusual circumstances. All staff will be trained by the Facility Director in an in-service training on 12/15/20 regarding these requirements and the Gaudenzia policies related to Incident Reporting. The Quality Assurance department will conduct at least quarterly reviews of the program in order to ensure compliance. The findings of these audits will be reviewed in regular CQI meetings following the audits. The Compliance department will conduct at least annual reviews to ensure compliance with corrective action plans. |
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
The project failed to file a written unusual incident report with the Department within 3 business days following an unusual incident involving events at the facility requiring the presence of police, fire or ambulance personnel.
On February 5, 2020, ambulance personnel responded to the facility and transported a client to the hospital. There was no documentation that an unusual incident was filed with the department.
On February 17, 2020, law enforcement responded to the facility. There was no documentation that an unusual incident was filed with the department.
On February 20, 2020, the fire department responded to the facility. There was no documentation that an unusual incident was filed with the department.
On March 22, 2020, law enforcement responded to the facility. There was no documentation that an unusual incident was filed with the department.
On April 27, 2020, ambulance personnel responded to the facility and transported a client to the hospital. There was no documentation that an unusual incident was filed with the department.
On April 29, 2020, ambulance personnel responded to the facility and transported a client to the hospital. There was no documentation that an unusual incident was filed with the department.
On August 11, 2020, law enforcement responded to the facility. There was no documentation that an unusual incident was filed with the department.
On August 28, 2020, ambulance personnel responded to the facility and transported a client to the hospital. There was no documentation that an unusual incident was filed with the department.
On October 9, 2020, ambulance personnel responded to the facility and transported a client to the hospital. There was no documentation that an unusual incident was filed with the department.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A written unusual incident report will be filed with the Department within 3 business days following an unusual incident involving an event at the facility requiring the presence of police, fire or ambulance personnel. All staff will be trained by the Facility Director in an in-service training on 12/15/20 regarding these requirements and the Gaudenzia policies related to Incident Reporting. The Quality Assurance department will conduct at least quarterly reviews of the program in order to ensure compliance. The findings of these audits will be reviewed in regular CQI meetings following the audits. The Compliance department will conduct at least annual reviews to ensure compliance with corrective action plans. |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
The project failed to document a complete client record on an individual which includes information relative to the client's involvement with the project that is to include follow-up information in two of four applicable client records reviewed.
Client #5 was admitted on July 28, 2020 and was discharged on September 1, 2020. There was no follow-up information documented in the client record.
Client #6 was admitted on May 6, 2020 and was discharged on July 28, 2020. There was no follow-up information documented in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A complete client record will be maintained for all individuals, which includes follow-up information for all discharged clients. All clinical staff will be trained by the Facility Director in an in-service training on 11/12/20 regarding these requirements and the use of the newly developed Follow-Up document in the electronic health record. This electronic form will replace our previous system of documenting this in a paper log binder. The Quality Assurance department will conduct at least quarterly reviews of the program in order to ensure compliance. The findings of these audits will be reviewed in regular CQI meetings following the audits. The Compliance department will conduct at least annual reviews to ensure compliance with corrective action plans. |