INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 25 - 26, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Ellen O'Brien Gaiser Addiction Center 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on the review of personnel /training records and the Staffing Requirement Facility Summary Report, the facility failed to ensure staff persons received the required HIV/AIDS and/or STD/TB training within the required timeframes in two of seven applicable records.
Employee # 10 was hired as a support staff on October 9, 2018. HIV/AIDS training was to be completed by October 9, 2020. There was no documentation the training had been completed prior to retirement on August 14, 2021.
Employee # 11 was hired as support staff on May 31, 2019. HIV/AIDS and STD/TB training was to be completed by May 31, 2021. There was no documentation the training had been completed as of the inspection date, August 26, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will be trained on communicable disease within two year period. HR director will conduct bi-annual audits of training to ensure that everyone is on target with their training and we are within timelines. Current active employees have produced their training records and HR will maintain and store documentation in HR office to be available upon request. |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based on observation, the facility failed to ensure exits from the facility were unobstructed. The rear exit was obstructed and unable to be opened from the inside of the building.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facilities coordinator will do building walkthroughs to check all exit doors monthly to ensure all can open unstructured. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility fire drill records, the facility failed to conduct unannounced fire drills at least once a month.
Written fire drill records were reviewed from September 2019 to July 2021. A fire drill for the month of June 2021 was not conducted.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
With changing of new facility management, the new facility coordinator will ensure that there is an unannounced monthly fire drill by the end of the month and will review the log book to ensure that all are within timelines. |
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on a review of the policy and procedure manual, the facility failed to have the project director sign a written manual delineating project policies and procedures. The last documented sign off was 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director will review policies and procedures with board executive committee annually and will sign off with board chair annually at review. |
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
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client in one of seven client records reviewed.
Client #4 was admitted on June 8, 2021 and discharged on July 26, 2021. The client record included documentation on July 9, 2021 that information was disclosed but there was not a release of information for that agency.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will review consent sign off policies with clinical staff and prior to releasing any information to 3rd parties, all counselors will be trained by Clinical Director to double check all releases before speaking to any outside provider. |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on the review of client records, the facility failed to obtain an informed and voluntary consent that included the name of the person, agency, or organization to whom disclosure was to be made, in one of seven client records.
Client #3 was admitted on April 27, 2021 and discharged on July 21, 2021. A release of information was signed by the client on May 10, 2021, but did not document the name of the person, agency, or organization to whom the information was to be released.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will train all clinical staff on appropriate consent release policies in morning staffings. After trainings, counselors will review their charts to ensure all information for requesting agency/person/organization is completely filled in and signed by client prior to disclosing any information. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to include the dated signature of the client in two of seven client records.
Client # 1 was admitted on April 12, 2021 and discharged on June 30, 2021. A release of information was signed by the witness on April 12, 2021 but did not include the client signature or date.
Client # 6 was admitted on July 26, 2021. A release of information was signed by the witness on July 26, 2021 but did not include the client signature or date.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will review consent policies with clinical staff and will do a random sampling of charts monthly ensuring consents are within compliance. New releases will be sought out for current active clients and clinical director will train clinical staff to ensure that they seek a dated signature from client. |
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 a review of client records, the facility failed to offer the client a copy of consents in two of seven records.
Client # 6 was admitted on July 26, 2021. A release of information was signed by the witness on July 26, 2021 but did not indicate a copy was offered. A release of information was signed by the client on August 4, 2021 but did not indicate a copy was offered.
Client # 7 was admitted on July 28, 2021. A release of information was signed by the client on July 29, 2021 but did not indicate a copy was offered.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will review the consent policies monthly with clinical staff and will have staff complete new consents for clients still active. Under the direction of clinical director, primary counselor will educate clients on consent policies and give them their consent copies, seeking their signature that copies have been received. |
709.32 (b) LICENSURE Medication control
§ 709.32. Medication control.
(b) Verbal orders for medication can be given only by a physician or other medical professional authorized by State and Federal law to prescribe medication and verbal orders may be received only by another physician or medical professional authorized by State and Federal law to receive verbal orders. When a verbal or telephone order is given, it has to be authenticated in writing by a physician or other medical professional authorized by State and Federal law to prescribe medication. In detoxification levels of care, written authentication shall occur no later than 24 hours from the time the order was given. Otherwise, written authentication shall occur within 3 business days from the time the order was given.
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Observations
Based on the review of client records, the facility failed to document the physician authenticated the verbal order within the required timeframe in two of six client records.
Verbal orders were to be signed by the physician within three business days.
Client # 1 was admitted on April 12, 2021 and discharged on June 30, 2021. A verbal order was taken on April 12, 2021. The physician ' s signature was not documented.
Client #3 was admitted on April 27, 2021 and discharged on July 21, 2021. Verbal orders were taken on April 27, 2021. The physician ' s signature was not documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Medical Director has been trained on verbal order policy and nurse will be responsible to place all verbal orders in an identified file where doctor can review three days a week to ensure that all verbal orders are signed within time frames. |
709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
Based on a review of client records, the facility failed to document medication in three of six client records. Client records #1, #3, and #4 included blank entries on the Medication Administration Record (MAR).
Client # 1 was admitted on April 12, 2021 and discharged on June 30, 2021. A medication that was to be given daily did not have any documentation for June 16, 2021.
Client #3 was admitted on April 27, 2021 and discharged on July 21, 2021. A medication that was to be given daily did not have any documentation for June 3, 2021.
Client #4 was admitted on June 8, 2021 and discharged on July 26, 2021. A medication that was to be given daily did not have any documentation for June 23, July 1, 13 and 19, 2021.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Medical Director and Facility Nurse will train all staff on medication policies, including documentation of the MAR and will audit medical charts quarterly to ensure compliance with the medication policy. |
709.34 (c) (5) 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:
(5) Outbreak of a contagious disease requiring CDC notification.
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Observations
Based on a review of administrative information, the facility failed to file a written unusual incident report with the Department within 3 business days following an outbreak of COVID 19.
Client # 1 was admitted on April 12, 2021 and discharged on June 30, 2021. A positive test was documented on June 15, 2021 and was not reported to DDAP.
Client #3 was admitted on April 27, 2021 and discharged on July 21, 2021. A positive test was documented on June 15, 2021 and was not reported to DDAP.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Facility Director and nurse have been trained in the reporting of unusual incidents and all unusual incidents will be reported within the reporting timeframe. Unreported facility incidents will be reported by facility director by 9/15. |
709.51(b)(1) LICENSURE Disclosure to client
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on a review of client records, the facility failed to document the disclosure of the criteria for admission to clients during intake in seven of seven client records.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will update client inpatient program handbook to reflect the criteria for admission and intake staff will seek signature upon admission that criteria for admission was reviewed. Clinical director will review updated handbook with active clients by 9/15/2021 and under the supervision of clinical director, primary counselor will review all intake paperwork for all new intakes monthly to ensure that clients sign off is in the record and counselor will initial and date that they have reviewed it. |