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 September 24, 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 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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705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
The facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room as Licensing Specialists could clearly hear counseling sessions coming from the counselor's office located near the common area of the facility.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 10/01/20, Program Director obtained additional sound machines that will be placed outside of all counseling rooms/offices to ensure client confidentiality/privacy. Moving forward, sound machines will be checked during weekly physical site inspections that will be conducted by Program Director or designee. Additionally, CQI/Compliance Department will ensure that sound machines are onsite/operable during quarterly physical site inspections. |
705.11 (2) (iii) LICENSURE Child care.
705.11. Child care.
(2) Interior space. The residential facility shall:
(iii) Maintain protective caps over each electrical outlet.
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Observations
The facility failed to ensure that all electrical outlets, within the facility, had protective caps over them. During the physical plant inspection, the following outlets were discovered to have missing protective caps:
-two outlets in the kitchen near the sink
-one outlet under a microwave cart at the kitchen entrance
-one outlet in a counseling office
-one outlet in the bathroom above the sink
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 09/25/20, Program Director obtained additional electrical outlet covers. Moving forward, all electrical outlets will be checked during weekly physical site inspections that will be conducted by Program Director or designee. Additionally, CQI/Compliance Department will ensure that electrical outlet covers are onsite during quarterly physical site inspections. |
705.11 (2) (iv) LICENSURE Child care.
705.11. Child care.
(2) Interior space. The residential facility shall:
(iv) Secure all hazardous and poisonous substances and materials with safety latches or locks.
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Observations
The facility failed to ensure that all hazardous and poisonous substances and materials were secured with safety latches or locks. During the physical plant inspection, cleaning solution materials were found stored in an unlocked lower cabinet located in the kitchen.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 09/25/20, Program Director removed hazardous materials. Effective immediately all hazardous materials are stored in the basement in a locked closet. Moving forward, all hazardous materials will be checked daily to ensure that the materials are properly stored. Additionally, CQI/Compliance Department will ensure that hazardous materials are stored properly during onsite quarterly physical site inspections |
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 failed to obtain a written, informed and voluntary consent to release information form from the client for the disclosure of information contained in the client record in four of seven client records reviewed.
Client #3 was admitted on August 3, 2020 and was active at time of inspection. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client prior to the disclosures.
Client #5 was admitted on March 23, 2020 and was discharged on July 16, 2020. There was documentation of disclosures to a government agency during the client's treatment episode; however, there was no consent to release information form signed by the client prior to the disclosures.
Client #6 was admitted on April 10, 2020 and was discharged on July 7, 2020. There was documentation of disclosures to a government agency during the client's treatment episode; however, there was no consent to release information form signed by the client prior to the disclosures.
Client #7 was admitted on May 27, 2020 and was discharged on September 7, 2020. There was documentation of disclosures to a government agency during the client's treatment episode; however, there was no consent to release information form signed by the client prior to the disclosures.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director conducted an inservice meeting with the clinical team on 10/01/20 regarding the completion of the Confidentiality Release/Request Forms. Moving forward, all client documentation will be reviewed by the Program Director or designee weekly to ensure consents are appropriately completed. Additionally, CQI/Compliance Department will conduct quarterly clinical chart audits ensuring that documentation/consents are completed appropriately.
All active client records, including those listed in the deficiency, will be reviewed to ensure that the appropriate disclosure consents (for individuals and entities involved in the clients' care) are completed and signed by the client by 11/18/20. |
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 facility failed to ensure that disclosures of client identifying information were maintained within the limits established by 4 Pa. Code 255.5 (b) for releases of information in four of seven client records reviewed.
Client # 2 was admitted on May 21, 2020 and was active at time of inspection A release of information form to a government agency, signed and dated by the client on May 21, 2020, that allowed for the release of progress notes, treatment plans, case consults and discharge summary, all of which exceeds the limits established by 4 Pa. Code 255.5. Additionally, a release of information form to another government agency, signed and dated by the client on May 21, 2020, that allowed for the release of progress notes, case consults and discharge summary, all of which exceeds the limits established by 4 Pa. Code 255.5. Finally, a release of information form to the funding source, signed and dated by the client on May 21, 2020, that allowed for the release of treatment plans, case consults, mental health records, progress notes and medical records, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #4 was admitted on February 3, 2020 and was discharged on August 3, 2020. A release of information form to the funding source, signed and dated by the client on February 3, 2020, that allowed for the release of psychological/psychiatric evaluations, progress notes, treatment plans, case consults and discharge summary, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #5 was admitted on March 23, 2020 and was discharged on July 16, 2020. A release of information form to the funding source, signed and dated by the client on March 23, 2020, that allowed for the release of psychological/psychiatric evaluations, progress notes, treatment plans, case consults and discharge summary, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #7 was admitted on May 27, 2020 and was discharged on September 7, 2020. A release of information form to the funding source, signed and dated by the client on May 27, 2020, that allowed for the release of psychological/psychiatric evaluations, progress notes, treatment plans, case consults and discharge summary, 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
The Program Director conducted an inservice meeting with the clinical team on 10/01/20 regarding the limitations of confidentiality when completing the disclosure consents. Moving forward, all client documentation, including the disclosure consents, will be reviewed by the Program Director or designee weekly to ensure consents are appropriately completed. Additionally, CQI/Compliance Department will conduct quarterly clinical chart audits ensuring that documentation/consents are completed appropriately.
All disclosure consents for all active clients, including those listed in the deficiency, will be reviewed to ensure that the consents do not exceed the limits established by 4 Pa. Code 255.5. Consents identified to exceed the limits will be identified as not valid in the record and new disclosure consents will be completed within required limits by 11/18/20. |
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 facility failed to ensure that all events at the facility, in which the presence of police, fire, or ambulance personnel are required, were reported to the Department within 3 business days, based on the review of the facility's unusual incident reports.
On May 3,2020, an ambulance was called to the facility and a client was transported to the hospital; however, there was no documentation that this incident was reported to the Department within 3 business days.
On May 12, 2020, an ambulance was called to the facility and a client was transported to the hospital; however, there was no documentation that this incident was reported to the Department within 3 business days.
On May 30, 2020, an ambulance was called to the facility and a client was transported to the hospital; however, there was no documentation that this incident was reported to the Department within 3 business days.
On June 18, 2020, an ambulance was called to the facility and a client was transported to the hospital; however, there was no documentation that this incident was reported to the Department within 3 business days.
On June 21, 2020, an ambulance was called to the facility and a client was transported to the hospital; however, there was no documentation that this incident was reported to the Department within 3 business days.
On June 26, 2020, an ambulance was called to the facility and a client was transported to the hospital; however, there was no documentation that this incident was reported to the Department within 3 business days.
On June 26, 2020, an ambulance was called to the facility and a client was transported to the hospital; however, there was no documentation that this incident was reported to the Department within 3 business days.
On June 28, 2020, an ambulance was called to the facility and a client was transported to the hospital; however, there was no documentation that this incident was reported to the Department within 3 business days.
On June 28, 2020, an ambulance was called to the facility and a client was transported to the hospital; however, there was no documentation that this incident was reported to the Department within 3 business days.
On July 5, 2020, an ambulance was called to the facility and a client was transported to the hospital; however, there was no documentation that this incident was reported to the Department within 3 business days.
On July 12, 2020, an ambulance was called to the facility and a client was transported to the hospital; however, there was no documentation that this incident was reported to the Department within 3 business days. .
On September 2, 2020, an ambulance was called to the facility and a client was transported to the hospital; however, there was no documentation that this incident was reported to the Department within 3 business days.
On September 7, 2020, an ambulance was called to the facility and a client was transported to the hospital; however, there was no documentation that this incident was reported to the Department within 3 business days.
These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
Program Director conducted an inservice with the clinical team on 10/01/20 regarding the completion and submission of reportable incidents to DDAP. Moving forward, the Program Director will review all incident reports within 24 hours to ensure that the reports have been appropriately completed and submitted per regulations. All incident reports will be reviewed on a monthly basis during the Eastern Region CQI meeting. Additionally, the Compliance Department will conduct quarterly incident review analyses. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
The facility failed to assure that counseling services were being provided according to the individual's treatment and rehabilitation plan in three of seven client records reviewed.
Client #3 was admitted on August 3, 2020 and was active at time of inspection. There was no documentation in the client record of individual counseling services occurring during the week of September 6, 2020 through September 12, 2020.
Client #4 was admitted on February 3, 2020 and was discharged on August 3, 2020. There was no documentation in the client record of individual counseling services occurring during the weeks of February 23, 2020 through February 29, 2020, April 12, 2020 through April 18, 2020, April 19, 2020 through April 25, 2020 and August 9, 2020 through April 15, 2020.
Client #6 was admitted on April 10, 2020 and discharged on July 7, 2020. There was no documentation in the client record of individual counseling services occurring during the week of May 24, 2020 through May 30, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director conducted an inservice meeting with the clinical team on 10/01/20 regarding individual and group sessions being provided as indicated by the clients' treatment plan. Moving forward, the Program Director or designee will review all active clients' weekly schedules to ensure that individual/group sessions are occurring per treatment plan. Additionally, CQI/Compliance Department will conduct quarterly clinical chart audits ensuring clinical services are occurring as required. |
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 facility failed to maintain a complete client record on an individual, which is to include follow-up information, in three of four applicable client records reviewed.
Client #4 was admitted on February 3, 2020 and was discharged on August 3, 2020. There was no follow-up information documented in the client record.
Client #5 was admitted on March 23, 2020 and was discharged on July 16, 2020. There was no follow-up information documented in the client record.
Client # 6 was admitted on April 10, 2020 and discharged on July 7, 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
Program Director conducted an inservice meeting with the clinical team on 10/01/20 regarding completing the follow-up documentation for all discharged clients Moving forward, the Program Director or designee will review all discharged records within 72 hours to ensure that discharge documentation has been appropriately completed. Additionally, CQI/Compliance Department will conduct quarterly clinical chart audits, including discharged records, ensuring that all discharged documentation has been completed as required. |
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
The facility failed to maintain a complete client record, which is to include verification that any work done by the client at the project is an integral part of their treatment and rehabilitation plan, in four of seven client records reviewed.
Client #2 was admitted on May 21, 2020 and was active at time of inspection. There was documentation of work and childcare therapy being completed by the client; however, the treatment and rehabilitaiton plans contained no documentation of work and childcare therapy.
Client #3 was admitted on August 3, 2020 and was active at time of inspection. There was documentation of work and childcare therapy being completed by the client; however, the treatment and rehabilitaiton plans contained no documentation of work and childcare therapy.
Client #4 was admitted on February 3, 2020 and was discharged on August 3, 2020. There was documentation of work and childcare therapy being completed by the client; however, the treatment and rehabilitaiton plans contained no documentation of work and childcare therapy.
Client #5 was admitted on March 23, 2020 and was discharged on July 16, 2020. There was documentation of work and childcare therapy being completed by the client; however, the treatment and rehabilitaiton plans contained no documentation of work and childcare therapy.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All active client treatment plans will be reviewed to ensure that work therapy including child care is prescribed in the clients; treatment plan by 11/14/20. Moving forward, the Program Director or Clinical Supervisor will review and approve all initial treatment plans and treatment plan reviews to ensure that work therapy including child care is appropriately prescribed in the client's treatment plan. Additionally, CQI/Compliance Department will conduct quarterly clinical chart audits ensuring work therapy/child care is included in the treatment plans. |