INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 5-8, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gaudenzia, 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:
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Plan of Correction
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705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill logs, the facility failed to prepare alternate exit routes to be used during fire drills.
Fire drill records were reviewed from July 2022 through June 2023. The facility conducted 31 fire drills which all utilized the back door exit during fire drills.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Recovery Support Supervisor, and Operations Manager will retrain all staff on the procedures for Fire Drills, and review policy. Training will be completed by 10/31/23. Fire Drill Log will be reviewed by Division Director and CQI Manager quarterly to monitor for compliance, including documentation that alternate exits are being utilized. Any issues noted will be brought to the attention of program management to be addressed immediately. |
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
Based on a review of client records, the facility failed to obtain an informed and voluntary consent to release information which includes the specific information to be disclosed in one of seven records.
Client #2 was admitted to the detoxification activity on February 17, 2023 and discharged on February 21, 2023. Three separate informed and voluntary consent dated February 17, 2023 to different agencies did not provide the specific information to be disclosed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CQI manager and Clinical Supervisor will conduct staff training focusing on correct completion of releases of information. Training will be completed by 10/31/23. CQI manager will create sample Releases of Information for various external sources to use as both training tools and handout for staff to reference. Any issues noted will be brought to the attention of program management to be addressed immediately. CQI will monitor with quarterly chart audits, Clinical Supervisor will monitor with monthly chart audits. |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent to release information which included the purpose for disclosure in one of seven records.
Client #2 was admitted to the detoxification activity on February 17, 2023 and discharged on February 21, 2023. Three separate informed and voluntary consents dated February 17, 2023 to different agencies did not indicate the purpose of disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CQI manager and Clinical Supervisor will conduct staff training focusing on correct completion of releases of information. Training will be completed by 10/31/23. CQI manager will create sample Releases of Information for various external sources to use as both training tools and handout for staff to reference. Any issues noted will be brought to the attention of program management to be addressed immediately. CQI will monitor with quarterly chart audits, Clinical Supervisor will monitor with monthly chart audits. |