INITIAL COMMENTS
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This report is a result of an onsite follow-up investigation to an incident report. The follow-up investigation was conducted on July 29, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up investigation, Gaudenzia - Crossroads Hall, 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 August 31, 2009.
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Plan of Correction
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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 on a review of client records, the facility failed to document informed and voluntary consent to release information prior to releasing client identifying information in two of five client records.
The findings include:
Five client records were reviewed on July 29, 2009 during an onsite follow up to an incident report. Documentation of informed and voluntary consent to release information was required in two client records. An incident report including client identifying information was provided to funding sources without valid consent to release information in two client records.
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Plan of Correction
Gaudenzia Erie's confidentialty policy adheres to PA 255.55. All written reports will adhere to this policy effective immediately. The Program Director/Supervisor will review the policy with clinical staff in the monthly staff meetings. This will be monitored through the QI/UR process. |
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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records and incident reports, the facility failed to protect the confidentiality of Drug and Alcohol treatment clients by failing to separate the Drug and Alcohol treatment population from the Community Corrections Population at the facility.
The findings include:
A an on site follow up to an incident report was conducted on July 29, 2009. The facility allowed residents of the Community Corrections activity to mix with residents of the residential drug and alcohol treatment activity. The facility failed to protect the confidentiality of the residents of the drug and alcohol treatment activity in that they could be easily identified as participants in drug and alcohol treatment by individuals who were not engaged in drug and alcohol treatment.
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Plan of Correction
Community Corrections residents and residents in D/A treatment will remain in separate programming and will not mix. Structural programmatic changes are being looked at to improve this as well. Staff will be trained on the separate programs by the Program Supervisor/Director. This will be monitored by the Program Supervisor/Director and the Division Director. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client in writing of a decision to involuntarily terminate treatment at the project.
The findings include:
Five client records were reviewed on July 29, 2009. One client record required documentation of written notice to the client of a decision to involuntarily terminate the client's treatment at the facility. There was no documentation of a written notice to the client of the decision to terminate the client's treatment at the facility.
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Plan of Correction
As per policy, clients will be notified in writing of involuntary termination of the program and a copy will be placed in client's file. This is effective immediately and will be monitored by Program Supervisors and the QI/UR process. |
709.51(a)(4) LICENSURE Involuntary discharge/termination criteria
709.51. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(4) Involuntary discharge/termination criteria.
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Observations
Based on a review of client records, the facility failed to follow the facility's involuntary termination policy.
The findings include:
Five client records were reviewed on July 29, 2009. One of the client records included an incident report involving an action by a client that would result in immediate termination. The client engaged in that act and was not involuntarily terminated. This same client is alleged to have perpetrated a subsequent act that led to the complaint investigation.
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Plan of Correction
Gaudenzia Erie will adhere to the policy on Involuntary Discharge. Each file will contain the documentation to support that. The Program Director/Supervisor will address this in monthly staff meetings. This is effective immediately. All involuntary discharges arereviewed and discussed in the monthly QI/UR meetings. |
709.53(a)(5) LICENSURE Progress Notes
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:
(5) Progress notes.
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Observations
Based on a review of client records, the facility failed to document progress notes in one of five client records.
The findings include:
Five client records were reviewed on July 29, 2009. One client record did not include progress notes regarding an incident that occurred in which he was involuntarily terminated from the program.
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Plan of Correction
Each client file will include a progress/discharge note indicating the nature of discharge. This is effective immediately and will be monitored by the Program Supervisors and the PI process monthly. |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based on client record review, the facility failed to document a discharge summary in one of five client records.
The findings include:
Five client records were reviewed on July 29, 2009. A discharge summary was not documented in one client record.
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Plan of Correction
Client files will adhere to policy and have discharge summaries within seven (7) days of discharge. This is effective immediately and will be monitored by Program Supervisors and the Administrative Assistant during the monthly QI/UR process. |