INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 24, 2025 through April 25, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the 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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709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on the review of client records, the project failed to offer a copy of release of information forms in one of seven client records reviewed.
Client #1 was admitted on February 17, 2025 and was a current client at the time of the inspection. There was no documentation that the client was offered copies of three release of information forms for a funding source, a pharmacy and a family member; signed and dated by the client on February 17, 2025.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Plan of Correction:
The Program Director will educate the administrative coordinator and staff on the proper way to conduct the release and consent process according to Pa.Code 709.38. The Program Director will then conduct an in-service training course for all the staff on completing release forms during the intake process and the imperativeness of offering all clients a copy of their singed release. In accordance with 709.28 par (d): a copy of client consent will be offered to the client and a copy maintained in the client record. All staff completing consents/released with give them to the Program Director to be viewed for compliance before being update to the EHR system.
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709.32 (c) (6) LICENSURE Medication control
§ 709.32. Medication control.
(6) Medication errors and drug reactions shall be recorded in the client record. This may be the medical record if a separate medical record is maintained for all clients.
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Observations
Based on a review of seven client records, the facility failed to record medication errors in the client record in four of seven records reviewed.
Client #2 was admitted on February 10, 2025 and was a current client at the time of the inspection. This client was prescribed Celexa and Seroquel one time a day, at bedtime; however, there is no documentation that the client received or refused these medications on February 26, 2025, March 12, 2025, and March 14, 2025.
Client #3 was admitted on February 25, 2025 and was a current client at the time of the inspection. This client was prescribed Klonopin one time in the afternoon; however, there is no documentation that this client received or refused this medication on March 20, 2024, March 24, 2024, and April 3, 2024. Additionally, this client was prescribed Olanzapine one time at bedtime; however, there is no documentation that this client received or refused this medication on March 14, 2025, March 15, 2025, April 13, 2025, April 14, 2025, and April 15, 2025.
Client #6 was admitted on November 19, 2024 and was discharged on February 21, 2025. This client was prescribed Lamotrigine and Seroquel one time a day, at bedtime; however, there is no documentation that the client received or refused these medications on January 3, 2025.
Client #7 was admitted on November 8, 2024 and was discharged on March 15, 2025. This client was prescribed Seroquel one time a day, at bedtime; however, there is no documentation that the client received or refused this medication on November 22, 2024, February 13, 2025, and February 21, 2025.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Plan of Correction
Medical errors will be monitored daily by the nursing team and the nurse manager. Incident reports will be completed by the nursing staff and presented within 24 hours and then sent to the Eastern Region Medical Division Director for review. Incident reports will also be sent to the appropriate community behavioral health entities for review. Moreover, any medication errors will also be appropriately documented by the facility's policy and addressed by the nursing team for immediate correction Effective 5/12/25, the organization's Nurse Manager will conduct a minimum quarterly medical services onsite audit at the facility. Findings will be documented using the CQI Department Medical Services Inspection Form. Any found issues that immediately impact the health and safety of clients will be immediately reported to the Division Director and/or the Eastern Region Medical Division Director, accompanied by an incident report if necessary. Findings will also be reported and documented in the monthly Eastern Region CQI Meetings. The Division Director and Eastern Region Medical Division Director will be responsible for ensuring that all medical services are provided according to regulatory requirements. |
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
Based on a review of seven client records, the facility failed to ensure that all work done by clients at the project is an integral part of their treatment and rehabilitation plan in five of seven records reviewed
Client #1 was admitted on February 17, 2025 and was a current client at the time of the inspection. A comprehensive treatment and rehabilitation plan was documented in the record on February 26, 2025; however, it did not document that all work done by clients at the project is an integral part of their treatment and rehabilitation plan.
Client #2 was admitted on February 10, 2025 and was a current client at the time of the inspection. A comprehensive treatment and rehabilitation plan was documented in the record on February 15, 2025; however, it did not document that all work done by clients at the project is an integral part of their treatment and rehabilitation plan.
Client #5 was admitted on January 23, 2025 and was discharged on February 10, 2025. A comprehensive treatment and rehabilitation plan was documented in the record on January 30, 2025; however, it did not document that all work done by clients at the project is an integral part of their treatment and rehabilitation plan.
Client #6 was admitted on November 19, 2024 and was discharged on February 21, 2025. A comprehensive treatment and rehabilitation plan was documented in the record on December 5, 2024; however, it did not document that all work done by clients at the project is an integral part of their treatment and rehabilitation plan.
Client #7 was admitted on November 8, 2024 and was discharged on March 15, 2025. A comprehensive treatment and rehabilitation plan was documented in the record on November 11, 2024; however, it did not document that all work done by clients at the project is an integral part of their treatment and rehabilitation plan.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Plan of Correction:
Program director and clinical team met and brainstormed ways to ensure that any work willing completed by clients is clinically quantified as being directly correlated or aligned to the client's prescribed plan of treatment and person-centered rehabilitation interventions of with As of 5/9/25, the clinical team will create documentation in such a way to highlight how task orientated groups are connected to a client's treatment goals, ADL and biomedical wellness and overall self-esteem. An in-service training for clinicians will be held on 5/14/25. The Clinical Supervisor, in conjunction with the program director, will facilitate weekly audits to ensure compliance as it relates to work engaged in by clients. The CQI department will monitor for compliance during meetings with the Clinical Supervisor for 6 months. Finally, the Program director will monitor these actions in weekly clinical meetings.
Completion date 11/07/2025. |