INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 20, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia DRC, Inc., 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 and a plan of correction is due on November 30, 2010.
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Plan of Correction
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705.22 (4) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it at least once every week.
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Observations
Based on a physical plant inspection conducted on October 19 & 20, 2010 and an interview with the Facility Director, the facility failed to provide covered containers for garbage/rubbish to prevent the penetration of insects and rodents.
The findings include:
On October 19, 2010 at approximately 10:30 AM and on October 20, 2010 at 1:30 PM - 3:00 PM a physical plant inspection was conducted. On both days, it was observed that the facility's dumpster lacked lids, one lid was missing and one was broken and half of the lid missing. The facility director confirmed that the covers were missing.
This deficiency was corrected prior to the licensing staff leaving the facility.
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Plan of Correction
During the DOH Division of Drug and Alcohol Licensure Visit on October 20, 2010 the deficiency was corrected prior to the licensing staff leaving the facility.
A training to review the storage of trash, garbage, and rubbish in covered containers will be facilitated on December 15, 2010. The training will ensure that all maintenance staff dispose of trash in the covered trash containers as required by the Division of Drug and Alcohol Licensure DOH Policy 705.22(4).
All storage of trash, garbage, and rubbish will be reviewed weekly and monitored during monthly Continuous Quality Improvement (CQI) meetings to ensure compliance, completion, and timelines by the OP Program Director.
Persons Responsible: Division Director, Operations Director, Outpatient Program Director.
Timeframe for Completion: January 20, 2011
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709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based upon a review of client records and a discussion with the Facility Director on October 20, 2010, the facility failed to comply with 4 Pa. Code 255.5 relating to projects and coordinating bodies: disclosure of client-oriented information.
The findings include:
On October 20, 2010, 10 client records were reviewed for consents to release information and client related correspondences. Ten out of ten records reviewed, #1-10 inclusive, contained documentation of client related correspondences to third party payers that exceeded 4 Pa. Code 255.5 .
In addition, the facility's consent to release information forms permitted the facility to act in reliance on a client's verbal consent to release information. This is in violation of 709.28 (c)
(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 shall be in writing and include, but not be limited to:
(1)Name of the person, agency or organization to whom disclosure is made.
(2)Specific information disclosed.
(3)Purpose of disclosure.
(4)Dated signature of client or guardian.
(5)Dated signature of witness.
(6) Expiration date of the consent.
Client #1 was admitted on 9/13/10. The consent to release information to a third party payer dated 9/8/10 requested for the release of the Pennsylvania Client Placement Criteria (PCPC) contents, some items included on the PCPC would exceed what is permitted under 4 Pa. Code
Consents to release information to government agencies and third party funding sources, all with expiration dates of 8/26/11, allowed the facility to act in reliance on a client's verbal consent to release information.
Client #2 was admitted on 9/21/10. The consent to release information to a third party payer dated 9/21/10, included the release of substances abused.
Consents to release information to government agencies and third party funding sources, all signed on 9/21/10, allowed the facility to act in reliance on a client's verbal consent to release information.
Client # 3 was admitted on 7/26/10. The consent to release information to a third party payer dated 7/26/10, included the release of substances abused.
Consents to release information to government agencies and third party funding sources, all signed on 7/26/10, allowed the facility to act in reliance on a client's verbal consent to release information.
Client #4 was admitted on 8/3/10. The consent to release information to a third party payer dated 8/16/10, included the release of substances abused.
Consents to release information to government agencies and third party funding sources, all signed on 8/16/10, allowed the facility to act in reliance on a client's verbal consent to release information.
Client #5 was admitted on 8/27/10. The consent to release information to a third party payer dated 8/5/10, included the release of substances abused.
Consents to release information to government agencies and third party funding sources, five signed on 8/5/10 and two signed on 8/27/10, allowed the facility to act in reliance on a client's verbal consent to release information.
Client #6 was admitted on 8/23/10. The consent to release information to a third party payer dated 7/15/10, included the release of substances abused.
Consents to release information to government agencies and third party funding sources, four signed on 7/15/10 and two signed on 8/23/10, allowed the facility to act in reliance on a client's verbal consent to release information.
Client #7 was admitted on 4/5/10. The consent to release information to a third party payer lacked a date and included the release of substances abused.
Consents to release information to government agencies and third party funding sources, all signed on 3/22/10, allowed the facility to act in reliance on a client's verbal consent to release information.
Client #8 was admitted on 4/29/10. The consent to release information to a third party payer dated 4/16/10, included the release of substances abused.
Consents to release information to government agencies and third party funding sources, all signed on 4/16/10, allowed the facility to act in reliance on a client's verbal consent to release information.
Client #9 was admitted on 1/16/10. The consent to release information to a third party payer dated 1/16/10, included the release of substances abused.
Consents to release information to government agencies and third party funding sources, all signed on 1/16/10, allowed the facility to act in reliance on a client's verbal consent to release information.
Client #10 was admitted on 3/9/10. The consent to release information to a third party payer dated 3/9/10, included the release of substances abused.
Consents to release information to government agencies and third party funding sources, all signed on 3/9/10, allowed the facility to act in reliance on a client's verbal consent to release information. .
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Plan of Correction
The word "verbal" has been taken out of the Confidentiality Request to Release Information Form and the agency Policy and Procedure Manual.
A record-keeping training to include a review of the revised Confidentiality Request to Release Information Form and Policy and Procedure standards will be facilitated on December 10, 2010 to ensure that all staff release client information per DOH Policy 709.28(a)(1) and 4 Pa. Code 255.5.
Request of additional information by Third Party Billing concerning the release of client information will be consistent with the Release of Information Form not to exceed 4 Pa. Code 255.5.
All consent to release information documentation and compliance timeframes will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings to ensure compliance, completion, and timelines by the Program Director.
In addition, all existing consents to release information forms in client records #1-10 that exceeded 4 Pa. Code 255.5 will be voided and new consent to release information will be completed where appropriate.
Persons Responsible: Division Director, Outpatient Program Director.
Timeframe for Completion: January 20, 2011
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709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based upon a review of client records and an interview with the Facility Director, both occurring on October 20, 2010, the facility failed to document the type and frequency of treatment and rehabilitation services in six of eight client records reviewed.
The findings include:
Eight client records were reviewed on October 20, 2010 for individual treatment and rehabilitation plans, six out of eight records reviewed, specifically # 3, 4, 5, 6, 7, & 8, contained treatment plans that lacked documentation of the type and frequency of treatment and rehabilitation services.
Client # 3 was admitted on 7/26/10 the individual treatment plan was conducted on 8/20/2010, but lacked the type and frequency of treatment and rehabilitation services.
Client # 4 was admitted on 8/23/10 the individual treatment plan was conducted on 8/20/2010, but lacked the type and frequency of treatment and rehabilitation services.
Client # 5 was admitted on 8/27/10 the individual treatment plan was conducted on 8/24/2010, but lacked the type and frequency of treatment and rehabilitation services.
Client # 6 was admitted on 8/23/10 the individual treatment plan was conducted on 10/9/2010, but lacked the type and frequency of treatment and rehabilitation services.
Client # 7 was admitted on 4/5/10 the individual treatment plan was conducted on 5/4/2010, but lacked the type and frequency of treatment and rehabilitation services.
Client # 8 was admitted on 4/29/10 the individual treatment plan was conducted on 6/30/2010, but lacked the type and frequency of treatment and rehabilitation services.
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Plan of Correction
A record-keeping training to include a review of the treatment planning systems will be facilitated on December 10. 2010. The training will ensure that all staff are trained to document the type and frequency of treatment and rehabilitation services which include individual and group sessions provided by our agency in the Treatment Plan and Treatment Plan Updates as required by the Division of Drug and Alcohol Licensure per DOH Policy 709.92(a)(2).
All treatment planning documentation to include type and frequency of treatment and rehabilitation services provided will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible: Division Director, Outpatient Program Director.
Timeframe for Completion: January 20, 2011
709.93(a)(11) Licensure Client Records
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709.93(a)(11) LICENSURE Client records
709.93. 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
Based upon a review of client records and an interview with the Facility Director, both occurring on October 20, 2010, the facility failed to document follow-ups within 30 days of discharge as per facility policy, in two of three records reviewed.
The findings include:
Three client records were reviewed on October 20, 2010 for follow-up information. Two out of three records reviewed, specifically # 8 & 9, lacked documentation of any follow-up. The Facility Director confirmed that the follow-ups were not in the records nor were they in a follow up log.
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Plan of Correction
A record-keeping training to include a review of client follow up within 30 days will be facilitated on December 10, 2010 to ensure that all staff document client follow up as required by the Division of Drug and Alcohol Licensure DOH Policy 709.93(a)(11).
All client follow up documentation and compliance will be reviewed weekly and monitored during monthly Continuous Quality Improvement (CQI) meetings to ensure compliance, completion, and timelines by the OP Program Director.
Persons Responsible: Division Director, Outpatient Program Director.
Timeframe for Completion: January 20, 2011
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