INITIAL COMMENTS
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This report is a result of an on-site licensure inspection conducted on May 28, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Washington House 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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705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a physical plant inspection, the facility failed to keep frozen food at or below 0 degrees Fahrenheit.
The findings include:
A physical plant inspection was conducted on May 28, 2015. The facility failed to keep frozen food at or below 0 degrees Fahrenheit.
The thermometer in the kitchen freezer displayed a temperature of 30 degrees Fahrenheit.
The findings were reviewed with facility staff during the licensing inspection
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Plan of Correction
Program Director contacted service/repair and the problem was fixed by 5/29/2015. Freezer has been serviced and hourly runs are being done on the temperature.
All frozen food is being kept at or below 0F.
House Managers check temperature during hourly checks. Any problem is communicated to the Program Director who calls the purchasing department for a service person to come out. |
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, the facility failed to comply with the limitations imposed by 4 Pa. Code 255.5 for an informed and voluntary consent for the disclosure of information in three of eight client records reviewed.
The findings include:
4 Pa. Code 255.5 states:
Information released to judges, probation or parole officers, insurance company, health or hospital plan or governmental officials, pursuant to paragraphs (1), (2), (4),(7), (8) or subsection (a) of this section, is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following.
(1) Whether the client is or is not in treatment.
(2) Client's prognosis.
(3) The nature of the project.
(4) A brief description of the client's progress.
(5) A short statement as to whether the client has relapsed
Eight client records requiring documentation of informed and voluntary consents were reviewed on May 28, 2015. The facility failed to obtain an informed and voluntary consent to release and/or failed to adhere to the limitations imposed by 255.5 in client records, # 3, 4 and 5.
Client # 3 was admitted to the facility on April 2, 2015, and was still an active client at the time of inspection. On May 13, 2015, the facility faxed client # 3's clinical documents; however, the facility failed to obtain consent to release for the disclosure of this information. There was no consent to release forms in client # 3's record at the time of review on 5/28/15.
Client # 4 was admitted to the facility on April 8, 2015, and was still an active client at the time of inspection. On April 10, 2015, the facility documented two consent to release forms that did not comply with the limitations imposed by 255.5.
The facility documented a consent to release that did not indicate to whom the information would be disclosed, the consent did not document the purpose of the disclosure, or contain the specific information to be disclosed and comply with the limitations imposed by 255.5. The consent to release documented, "information about her treatment."
Client # 5 was admitted to the facility on April 2, 2015, and was still an active client at the time of inspection. The facility failed to obtain an informed and voluntary consent to release and/or failed to adhere to the limitations imposed by 255.5 in client record # 5.
1. On April 8, 2015, the facility documented a consent to release that did not indicate to whom the information would be disclosed or the purpose of the disclosure.
2. On May 22, 2015, the facility faxed client # 5's detailed comprehensive bio-psychosocial summary which included a substance abuse history, psychiatric evaluation and urine drug screens to the probation officer.
Additionally, the facility failed to ensure the clients confidentiality by having clients, who are not drug and alcohol clients, housed in the following bedrooms of the rehabilitation facility; 3, 4, 5 & 6.
The findings were reviewed with facility staff during the licensing process
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Plan of Correction
Program Director conducted in-service training with staff on 05/28/2015 after the inspection. The in-service related what should be in the consent to release information to ensure confidentiality. The five areas are: with consent; (1) whether the client is or is not in treatment; (2) Client's prognosis; (3) The nature of the project; (4) A brief description of the client's progress; (5) A short statement as to whether the client has relapsed.
Clinical Supervisor will review consent to release information for appropriateness during monthly chart review. Clinical Supervisor will re-do releases with the clients and have in charts by 06/15/2015.
All client's consent to release information, will follow these regulations.
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709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to develop an individual treatment and rehabilitation plan which included type and frequency in four of eight records reviewed.
The findings include:
Eight client records were reviewed on May 28, 2015, for documentation of an individualized treatment and rehabilitation plan. The facility failed to develop an individualized treatment plan which included type and frequency on the treatment plan in client records, # 2, 3, 4, and 5.
Client # 2 was admitted to the facility on March 30, 2015, and was still an active client at the time of inspection. The facility documented the individual treatment plan on April 3, 2015; however, the plan did not include the type and frequency of treatment services.
Client # 3 was admitted to the facility on April 9, 2015, and was still an active client at the time of inspection. The facility documented the individual treatment plan on April 14, 2015; however, the plan did not include the type and frequency of treatment services.
Client # 4 was admitted to the facility on April 8, 2015, and was still an active client at the time of inspection. The facility documented the individual treatment plan on April 10, 2015; however, the plan did not include the type and frequency of treatment services.
Client # 5 was admitted to the facility on April 2, 2015, and was still an active client at the time of inspection. The facility documented the individual treatment plan on April 2, 2015; however, the plan did not include the type and frequency of treatment services.
The findings were reviewed with facility staff during the licensing process
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Plan of Correction
Program Director will review charts monthly for compliance. Clinical Supervisor will ensure that all sections of the treatment plan are completed prior to signing off on the plan.
The Clinical Supervisor is doing supervision 1x per month with each clinical staff person(s) in writing appropriate treatment plans. This will continue until 09/30/2015. |
709.14(a) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(a) A license applies to the person, the named facility, the premises designated therein and the activities noted, and is not transferable.
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Observations
Based on a physical plant inspection and an interview with the Facility Director, the facility failed to comply with their drug and alcohol license.
The findings include:
A physical plant inspection was conducted on May 28, 2015. The facility is licensed by the Division of Drug and Alcohol Program Licensure for a maximum client capacity of 25 Inpatient Non-Hospital Drug-Free beds.
The facility failed to comply with their drug and alcohol license by housing non-drug and alcohol clients within the drug and alcohol facility. At the time inspection, there were 10 drug and alcohol clients and 9 non-drug and alcohol clients in the facility.
The drug & alcohol clients were identified to be in:
Bedroom # 1 - 3 clients
Bedroom # 2 - 4 clients
Bedroom # 6 - 3 clients
However, the facility presented a floor plan that showed that there were non-drug and alcohol clients located in the following rooms:
Bedroom 3 - 2 non-drug & alcohol clients
Bedroom 4 - 3 non-drug & alcohol clients
Bedroom 5 - 4 non-drug & alcohol clients
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
At the time of the site inspection, the clients residing in bedrooms, 3, 4, and 5, were not included on the census sheet. For future inspections, the Program Director will ensure that a complete census sheet showing all clients in residence shall be given to the licensing specialist. The Division Director will review with the Program Director prior to the site inspection to ensure that it is correct.
The Division Director and the Program Director will ensure compliance with having Drug and Alcohol clients clearly defined on the census sheet.
The census sheet was amended by the Program Director to show each client housed at Washington House.
The facility will adhere to a restricted license and comply with drug and alcohol licensing standards.
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