INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 9, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia - New Destiny 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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705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
The physical plant inspection was conducted on June 9, 2017. There was water damage to the exterior walls of bedrooms #5, #8 and the bathroom in room #6, as evidenced by crumbling plaster and peeling paint inside the rooms.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Following the inspection maintenance staff sanded and painted the damaged walls. Staff will continue to do regular inspections to be able to monitor water or any other damage and report it immediately to make sure it is taken care of as needed. |
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
Seven client records were reviewed on June 9, 2017. The facility exceeded 4 PA. Code in client record #6.
4 Pa. Code states:
Information released to judges, probation or parole officers, insurance company, health or hospital plan or governmental officials, pursuant to paragraphs (1), (2), (4),(7), (8) or subsection (a) of this section, is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following.
(1) Whether the client is or is not in treatment.
(2) Client's prognosis.
(3) The nature of the project.
(4) A brief description of the client's progress.
(5) A short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse.
Client #6 was admitted into treatment on January 4, 2017 and was discharged on April 24, 2017. The client record contained a consent to release information form for a probation officer, dated January 4, 2017, which identified that the following information was permitted to be released: presence in treatment, nature of the program, progress, relapse and frequency of relapse. Documentation in the client record indicated that the facility released information to the probation officer that exceeded 4 PA. Code on January 16, 2017. Specifically, a discharge summary that included the client's specific drugs of choice, route of administration, employment history, educational history, spiritual beliefs and trauma history.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director held a supervision session with the clinical staff to review the need for confidentiality when releasing information to ensure it does not exceed 4 PA code. The counselors are also being signed up for refresher courses on Confidentiality.The clinical supervisor with also be monitoring and reviewing outgoing information. |
709.30 (3) 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.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Seven client records were reviewed on June 9, 2017. The facility failed to document written acknowledgement by clients that they have been notified of all their rights as the following rights were not listed on the Client Rights Form:
* The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the infromation may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
* Clients have the right to appeal a decision limiting access to their records to the director.
* Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
"Gaudenzia will ensure that all Clients are fully informed of their rights as per DDAP regulations. Relevant sections of existing Gaudenzia, Inc. policy will be added to the client orientation materials which will be reviewed with the client at the beginning of treatment who will sign to indicate that they have received and understand all orientation materials. The Program Director will ensure that this is completed by July 30th, 2017. The regular CQI audits at each program will be utilized on a monthly basis to monitor completion of orientation sign off." |
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
Seven client records were reviewed on June 9, 2017. The facility failed to file a written unusual incident report with the Department within 3 business days following an unusual incident involving a physical assault or sexual assault by staff or a client.
Client #7 was admitted into treatment on August 8, 2016 and was discharged on December 1, 2016. A progress note contained in the client record, dated November 28, 2016, stated that the client "touched a peer aggressively". Additionally, there was a contact form contained in the record, dated November 28, 2016 which documented a conversation between the Facility Director and the client's caseworker, which stated that they discussed the issues regarding the client "including her assault of another client". An interview with the Facility Director confirmed that an unusual incident report was not filed with the Department.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An Unusual Incident Report was completed and was faxed to DDAP on 6/22/2017. Program Director met with staff to discuss the need to do Unusual Incidents. We reviewed § 2380.17. Reporting of Unusual Incidents which was provided to the staff along with the form for the the Unusual Report. We also went over the form to make sure everyone understood how it was to be done. Program Director and Clinical Supervisor will monitor all incidents to ensure reports are being made to DDAP when required. |