INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 23, 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, inc. People with Hope/Short-Term Program 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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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 the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one of ten client records reviewed.
Client #4 was admitted on November 11, 2020 and was discharged on December 13, 2020. It is documented in the client records that the client funding source eligibility was determined at admission, November 11, 2020; however, a release of information form was not documented until December 13, 2020.
These findings were reviewed with project staff during the licensing process.
This is a repeat citation from last year's licensure renewal inspection.
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Plan of Correction
The Program Director and/or Clinical Supervisor will review Confidentiality and Releases of Information with staff during staff in-service by 08/06/2021.
In addition, the Director and/or Clinical Supervisor will monitor confidential releases of information during monthly file audits and address discrepancies during staff supervisions.
The CQI department will monitor confidentiality and releases of information during quarterly CQI file audits and will report findings to the Program Director.
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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 the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the specific information to be disclosed in one of ten client records reviewed.
Client #10 was admitted on June 2, 2021 and was a current client at the time of the inspection. A release of information form for a family member, signed and dated on June 2, 2021, did not document the specific information to be disclosed.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Director and/or Clinical Supervisor will review Confidentiality and Releases of Information with staff during staff in-service by 08/06/2021.
In addition, the Clinical Supervisor will monitor confidential releases of information during monthly file audits and address discrepancies during staff supervisions.
The CQI department will monitor confidentiality and releases of information during quarterly CQI file audits and will report findings to the Program Director.
Client #10 discharged from the site on 6/25/2021
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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 the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the purpose of disclosure in one of ten client records reviewed.
Client #10 was admitted on June 2, 2021 and was a current client at the time of the inspection. A release of information form for a family member, signed and dated on June 2, 2021, did not document the purpose of disclosure.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Director and/or Clinical Supervisor will review Confidentiality and Releases of Information with staff during staff in-service by 08/06/2021.
In addition, the Director and/or Clinical Supervisor will monitor confidential releases of information during monthly file audits and address discrepancies during staff supervisions.
The CQI department will monitor confidentiality and releases of information during quarterly CQI file audits and will report findings to the Program Director.
Client #10 discharged from the site on 6/25/2021.
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709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the date, event or condition upon which the consent will expire in two of ten client records reviewed.
Client #3 was admitted on December 7, 2020 and was discharged on December 21, 2020. A release of information form for the funding source, signed and dated on December 8, 2021, did not document a date, event or condition upon which the consent will expire. Additionally, a release of information form for a case manager, signed and dated on December 16, 2021, did not document a date, event or condition upon which the consent will expire.
Client #4 was admitted on November 11, 2020 and was discharged on December 13, 2020. A release of information form for a family member, signed and dated on November 17, 2020, did not document a date, event or condition upon which the consent will expire.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Director and/or Clinical Supervisor will review Confidentiality and Releases of Information with staff during staff in-service by 08/06/2021.
In addition, the Clinical Supervisor will monitor confidential releases of information during monthly file audits and address discrepancies during staff supervisions.
The CQI department will monitor confidentiality and releases of information during quarterly CQI file audits and will report findings to the Program Director.
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709.34 (c) (4) 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:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on the review of the unusual incidents log, the project failed to file a written unusual incident report with the Department within three business days following an unusual incident involving an event at the facility requiring the presence of police, fire or ambulance personnel.
On April 15, 2021, it was documented in the unusual incident log that a client was transported to the hospital by ambulance. The project failed to file a written unusual incident report with the Department regarding this incident.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Program Director has reviewed and faxed the specific information listed for 4/15/2021 to DDAP. All unusual incident reports noted as of 07/23/2021.
The Program Director will review the incident log on a weekly basis to ensure that all reports are sent to the Department within 3 days.
In addition, on a quarterly basis the CQI Department will review the incident log to ensure compliance and report findings to the Program Director.
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709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on the review of client records, the project failed to ensure that counseling services are provided according to the individual treatment and rehabilitation plan in three of ten client records reviewed.
Client #6 was admitted on April 23, 2021 and was discharged on May 24, 2021. A comprehensive treatment and rehabilitation plan documented in the client record on April 24, 2021, indicated that the client was to receive one individual counseling session per week; however, there were no individual counseling sessions documented in the client record for the weeks of April 25, 2021 through May 1, 2021, May 9, 2021 through May 15, 2021 and May 16, 2021 through May 22, 2021.
Client #9 was admitted on May 27, 2021 and was an active client at the time of the inspection. A comprehensive treatment and rehabilitation plan documented in the client record on June 1, 2021, indicated that the client was to receive one individual counseling session per week; however, there were no individual counseling sessions documented in the client record for the weeks of June 6, 2021 through June 12, 2021 and June 13, 2021 through June 19, 2021.
Client #10 was admitted on June 2, 2021 and was a current client at the time of the inspection. A comprehensive treatment and rehabilitation plan documented in the client record on June 2, 2021, indicated that the client was to receive one individual counseling session per week; however, there were no individual counseling sessions documented in the client record for the week of June 6, 2021 through June 12, 2021.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Program Director and/or Clinical Supervisor will review Treatment Plans including the provision of services in accordance with the treatment plan. The Director will also review the proper documentation of "missed" sessions, with all clinical staff during an in-service by 08/06/2021.
In addition, the Program Director and/or Clinical Supervisor will monitor the provision of services during monthly file audits and address discrepancies during staff supervisions.
The CQI department will monitor the provision of services during quarterly CQI file audits and will report findings to the Program Director.
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709.53(a)(8) LICENSURE Case Consultation 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:
(8) Case consultation notes.
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Observations
Based on the review of client records, the project failed to document a complete client record that included case consultation notes in four of ten client records reviewed.
Client #3 was admitted on December 7, 2020 and was discharged on December 21, 2020. Case consultation notes were not documented in the client record.
Client #4 was admitted on November 11, 2020 and was discharged on December 13, 2020. Case consultation notes were not documented in the client record.
Client #5 was admitted on January 18, 2021 and was discharged on January 27, 2021. Case consultation notes were not documented in the client record.
Client #6 was admitted on April 23, 2021 and was discharged on May 24, 2021. Case consultation notes were not documented in the client record.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Program Director and/or Clinical Supervisor will review Case Consultation with all clinical staff during an in-service by 08/06/2021.
In addition, the Program Director and/or Clinical Supervisor will monitor Case Consultations during monthly file audits and address discrepancies during staff supervisions.
The CQI department will monitor Case Consultations during quarterly CQI file audits and will report findings to the Program Director.
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