INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 25-26, 2017, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Erie Inc. Satellite Office 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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705.28 (a) (1) (v) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
The facility failed to ensure the interior exit was lit at all times.
The ceiling light next to the bathroom at the rear entrance of the building was not working at the time of the onsite inspection, but the facility has evening hours on Wednesdays.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Operations Manager/Maintenance Worker will replace lights/bulbs in the ceiling light next to the bathroom at the rear of the building by 11/30/2017.
Operations Manager/Maintenance Worker will complete monthly facility runs to ensure all lighting is working appropriately. Monthly facility runs will begin in November 2017. |
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
The facility disclosed client information after the informed and voluntary consent forms expired for clients in one of seven client records reviewed.
There were informed consent to release information forms for client #6, that were signed on 06/15/2017, and expired on 06/15/2017. The releases of information were for the client's county probation office, and for two payment sources for the client's treatment.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Program Director will meet with all staff and train staff on confidentiality and how to complete releases of information correctly. Program Director will complete this training by 11/30/2017.
Program Director will complete monthly chart audits to ensure that releases of information are current and completed appropriately. These monthly chart audits will begin in November 2017.
Program Director will report chart audit results in the agencies monthly quality improvement meeting starting 12/20/2017. |
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
The facility failed to document written acknowledgement by the client that they were notified of all of their rights in seven of seven client records reviewed during the onsite inspection.
There was no documentation that the client was informed that the project director, facility director or clinical director may temporarily remove portions of the records prior to the inspection, if determined it may be detrimental to treatment; the reason for removal would be documented in the client's record; that the client has a right to appeal the decision to remove information and that the client had the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their record in client records # 1, 2, 3, 4, 5, 6 and 7.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
Division Director will review and adjust agency policy as needed to ensure all required client rights are listed in rights that are reviewed with clients upon admission. Division Director will complete this review by 11/14/2017.
Division Director will review agency policy/client rights with the Program Director by 11/17/2017.
Program Director will review updated policy/client rights with all staff by 11/21/2017.
Staff will begin using updated policy/client rights with all clients starting 11/22/2017.
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