INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 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, Gaudenzia Outpatient 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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705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room in that a client session could be heard from room B4 during the licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The program has ordered more sound diffusing devices to be placed in the group room next to this specific office as well as an additional machine to be placed directly outside of the counseling office in the hallway. Devices will be placed as soon as they arrive at facility. Target date of arrival 6/23/2021. Program Director will test to ensure that the counseling session cannot be overheard while in the hallway or group room. |
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 the review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record to include a dated client signature on four out of the seven client records reviewed.
Client #8 was admitted on January 11, 2021 and was still an active client at the time of the inspection. A release of information form for a medical professional, signed and dated by a witness on January 8, 2021, did not have a client signature; the informed and voluntary consent listed COVID 19 verbal consent.
Two releases of information forms for funding sources, signed and dated by the witness on January 8, 2021, did not have a client signature; the informed and voluntary consent listed COVID 19 verbal consent.
A release of information form for a government agency, signed and dated by the witness on January 8, 2021, did not have a client signature; the informed and voluntary consent listed COVID 19 verbal consent.
Client #9 was admitted on February 2, 2021 and was still an active client at the time of the inspection. A release of information form for the funding source, signed and dated by a witness on January 25, 2021, did not have a client signature; the informed and voluntary consent listed COVID 19 verbal consent.
A release of information form for a government agency, signed and dated by the witness on January 25, 2021, did not have a client signature; the informed and voluntary consent listed COVID 19 verbal consent.
A release of information form for a family member signed and dated by the witness on January 25, 2021, did not have a client signature; the informed and voluntary consent listed COVID 19 verbal consent.
A release of information form for a government agency, signed and dated by the witness on February 5, 2021, did not have a client signature; the informed and voluntary consent listed COVID 19 verbal consent.
Client #10 was admitted on February 22, 2021 and was still an active client at the time of the inspection. Two releases of information forms for a government agency signed and dated by the witness on February 17, 2021, did not have a client signature; the informed and voluntary consent listed COVID 19 verbal consent.
A release of information form for the funding source, signed and dated by the witness on February 17, 2021, did not have a client signature; the informed and voluntary consent listed COVID 19 verbal consent.
Client #14 was admitted on December 15, 2020 and was discharged on May 4, 2021. A release of information form for a funding source was signed and dated by a witness on December 10, 2020, did not have a client signature; the informed and voluntary consent listed COVID 19 verbal consent.
A release of information form for a family member, signed and dated by a witness on December 10, 2020, did not have a client signature; the informed and voluntary consent listed COVID 19 verbal consent.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
A docusign process has been developed in which consent forms can be electronically sent to each client for them to sign. Administrative staff sends the forms prior to initial appointment. Clinician assures that these signatures are obtained by first appointment at time of evaluation. This process has been in place for a few months and is effective immediately and on-going. |
709.83(a)(10) LICENSURE Client records
709.83. 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 a review of client records, the facility failed to have a complete client record on an individual which includes information relative to the client ' s involvement with the project to include having a discharge summary on five out of seven client records.
Client #2 was admitted on September 4, 2020 and discharged on October 30, 2020.
Client #3 was admitted on February 25, 2021 and discharged on March 5, 2021.
Client # 5 was admitted on December 31, 2020 and discharged on January 8, 2021.
Client # 6 was admitted on February 9, 2021 and discharged on February 25, 2021.
Client # 7 was admitted on January 26, 2021 and discharged on March 8, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will run a weekly discharge report in the EHR system to detail the current discharges. Clinical Supervisor will then audit each file to ensure successful completion of Discharge Summary with each clinician. This will be addressed in clinical staff meeting on 6/25/21 by Clinical Supervisor at which time this process will begin. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation in client records in three out of seven records reviewed.
Client #10 was admitted on February 22, 2021 and was still an active client at the time of the inspection.
Client #13 was admitted on December 29, 2020 and was discharged on February 4, 2021.
Client #14 was admitted on December 15, 2020 and was discharged on May 4, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A workflow document has been initiated and reviewed with all clinicians as of 6/18/21. This workflow details all required forms and documentation to be completed by the clinician as well as the time period to be completed by. The psychosocial evaluation is to be completed, per this workflow, on the first scheduled evaluation appointment with the client. Clinical Supervisor will complete regular chart audits to ensure compliance. |
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 on a review of client records, the facility failed to have a complete client record on an individual which includes information relative to the client ' s involvement with the project to include follow up information as per the project ' s policy within thirty days of a successful discharge on three out of the seven records reviewed.
Client #11 was admitted on July 30, 2020 and was discharged on December 17, 2020.
Client # 12 was admitted September 30, 2020 and was discharged on March 26, 2021.
Client #13 was admitted on December 29, 2020 and was discharged on February 4, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Administrative Support Staff will run a daily report in the EHR system to identify which successfully discharged clients are due for their 30 day follow up within 30 days of completion. Administrative Staff will then make these follow up contact attempts with each identified client and document accordingly. Clinical Supervisor and/or Administrative Coordinator will complete weekly audits in regard to the 30 day follow up process to ensure compliance. This will be reviewed with the Administrative Staff in a meeting on 6/25/2021. |