INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 4, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Focus 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 (c) (2) (i) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(2) Maintain at least one portable fire extinguisher with a minimum of an ABC rating in each kitchen.
(i) This fire extinguisher shall meet the requirement of one portable fire extinguisher for a 2,000 square foot area.
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Observations
Based on a physical plant inspection on May 9, 2022, the facility failed to ensure that the kitchen contained an ABC rated fire extinguisher.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On May 10, 2022 Philadelphia Detection placed a ABC rated fire extinguisher inside the kitchen.
Program Supervisor will do facility walk throughs to ensure that all fire extinguishers are placed according to regulations monthly.
Facility Residential Support Professionals do hourly house runs daily and will report any issue directly to the Program Supervisor regarding fire extinguishers.
DDAP inspector came to the site and observed that the ABC rated fire extinguisher had been placed inside the kitchen. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a review of administrative documents submitted, the project failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
The project's last annual financial audit was for the years ending June 30, 2020 and 2019.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
Gaudenzia, Focus House Corporate Office will ensure that a independent certified public account provides a annual financial audit of the projects drug/alcohol abuse services for all member funds.
Gaudenzia, Corporate Office will have a independent certified account provide a audit for Gaudenzia, Focus House beginning in September 2022.
Documentation and findings of the annual independent financial audit will be kept on file at the program site for review upon request.
Indpendent financial audits will be completed annually. |
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
Based on a review of seven client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in three records reviewed. Additionally, the facility failed to keep disclosures of client identifying information with the limits established by Pa Code 255.5 (b) in one record reviewed.
Client #4 was admitted on October 7, 2021 and discharged on February 2, 2022. The record contained documentation of identifying information and lab work released to a diagnostic laboratory on January 22, 2022, and January 3, 2022, to whom there was no client signed consent to release information form. The record contained documentation of a call to a probation officer on November 24, 2021, to whom there was no client signed consent to release information form. Additionally, the record contained documentation of information sent to a government agency on February 8, 2022, that contained the substance used in a relapse, which exceeds the limits established in Pa Code 255.5(b).
Client #5 was admitted on March 1, 2022 and was active at the time of the inspection. The record contained documentation of personally identifying information and medication records faxed to a pharmacy on March 2, 2022, to whom there was no client signed consent to release information form.
Client #7 was admitted on July 15, 2020 and was active at the time of the inspection. The record did not contain a client signed consent to release information form to the funding source between July 15, 2021, and January 15, 2022, however, the record contained evidence that billing occurred during that time period.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #4 completed a voluntary consent form for Atlantic Diagnostic.
All members will complete voluntary consents for Atlantic Diagnostic.
All new admission will complete voluntary consent for Atlantic Diagnostic at the time of admission
Client #5 completed voluntary consent for West Girard Pharmacy.
All members will complete voluntary consent for West Girard Pharmacy.
All new admission will complete voluntary consent for West Girard Pharmacy.
Client #7 completed voluntary consent for OMH/CBH-funding source.
All member will complete voluntary consent for OMH/CBH funding source.
All new admission will complete volutary consent for OMH/CBH funding source upon admision.
The Administrative Assistant will ensure during the admission process that all new members complete voluntary consent forms for all external supports and services.
Case Manager, will also review new member files during initial intake to ensure that all voluntary consent forms have been completed for member for all family, and external support and services.
Program Supervisor will review all member files monthly ensure that all member consents are present, have been signed and dated and are updated annuall.y |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of seven client records, the facility failed to ensure that informed and voluntary consent from the client for the disclosure of information forms included the dated signature of the client in one record reviewed.
Client #7 was admitted on July 15, 2020 and was active at the time of the inspection. The record contained a consent to disclose information form to a treatment provider on April 11, 2022, that was missing the dated signature of the client.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Administrative Assistant will ensure during admission of all new members that all voluntary consents are signed and dated by each member.
The Administrative Assistant did complete a voluntary consent for the member that contains his date and his signature.
Case Manager, will review admission paperwork during initial intake and ensure that all voluntary consents were signed and date by member. CM will also inquire as to if there are any personal or other supports that will require voluntary consent as well as initiate voluntary consent for other entities required as a support for continuity of care for each member.
Program Supervisor will review all member charts monthly and ensure that all voluntary consents required for continuity of care for each member is obtained, signed and dated by each member.
Program Supervisor will also ensure that all consents are updated annually. |
709.28 (c) (5) 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:
(5) Dated signature of witness.
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Observations
Based on a review of seven client records, the facility failed to ensure that informed and voluntary consent from the client for the disclosure of information forms included the dated signature of the witness in one record reviewed.
Client #7 was admitted on July 15, 2020 and was active at the time of the inspection. The record contained a consent to disclose information form to a treatment provider on April 11, 2022, that was missing the dated signature of the witness.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #7 signed and dated voluntary consent for treatment provider on May 6, 2022. The Administrative Assistance also witnessed and signed and dated the voluntary consent.
The Administrative Assistant will ensure during admission of all new members that all voluntary consents are signed dated by each member prior to disclosing any information to external entities regarding the member.
When members are admitted and then referred to treatment services a voluntary consent will be signed and dated by the member and signed and dated by the witness (staff) in order to provide collaboration between external organizations and Gaudenzia in our efforts to provide collaborative services for our members.
Case Manager, will review admission paperwork during initial intake and ensure that all voluntary consents were signed and date by member. CM will also inquire as to if there are any personal or other supports that will require voluntary consent as well as initiate voluntary consent for other entities required as a support for continuity of care for each member.
Program Supervisor will review all member charts monthly and ensure that all voluntary consents required for continuity of care for each member is obtained, signed and dated by each member and signed and dated by a witness (staff).
Program Supervisor will also ensure that all consents are updated annually with signature and date of the member and a witness (staff) .
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709.72(a)(3) LICENSURE Medication records
709.72. 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:
(3) Medication records.
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Observations
Based on a review of client records and a discussion with facility staff, the facility failed to include medication records in all closed records as the facility stated they destroy all medication logs after the client is discharged.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
All Medication Administration Records for all members will be filed in members chart for the total of 4 years after discharge for review upon request.
All member charts containing medication administration records will be kept in the Health and Wellness office for a total of 4 years after discharge for review upon request.
The Program Supervisor and MH Housing Division Director will review discharge record and Mar's date and sign off then file them prior to them being filed for review upon request. |