INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection. The inspection will be divided into two parts. 1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist. 2, an abbreviated on-site inspection, will be conducted on-site, at a later date and will include a review of client/patient records, and a physical plant inspection.This report is a result of Part 1, an abbreviated off-site inspection, conducted on October 28, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.Based on the findings of Part 1, an abbreviated off-site inspection, Gage House, LP 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) (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 on October 28, 2020, the facility failed to document a completed consent to release information form in client #3.Client #3 was admitted on October 16, 2020 and was still active at the time of the inspection. A consent to release information form dated October 16, 2020 to a pharmacy had "other" listed for information to be disclosed but did not document what additional items may be released. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client number three signed a correctly completed release of information on 11/3/20. Training was conducted during staff meeting on 11/3/20 to review the proper completion of releases of information. Reviewed the expected process when the 'Other" box is checked on a release of information: staff must specify what other information is to be released. Program leadership will monitor releases of information for proper completion during weekly chart audits, and/or staff supervision meetings. |
709.52(a)(2) LICENSURE Tx type & frequency
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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records on October 28, 2020, the facility failed to document type and frequency, as the treatment plans for clients # 1, 2 and 7 documented the range of 7-10 clinical groups per week in lieu of a definitive number of group sessions per week. Client #1 was admitted on August 26, 2020 and was still active at the time of the inspection. The treatment plan was dated August 26, 2020.Client #2 was admitted on September 22, 2020 and was still active at the time of the inspection. The treatment plan was dated September 24, 2020.Client #7 was admitted on March 5, 2020 and discharged on March 19, 2020. The treatment plan was dated March 7, 2020.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Training was provided to clinical staff on 11/3/2020 by program leadership regarding the specifications for type and frequency of services on the treatment plans. Clinicians will indicate the specific number of groups therapy sessions expected weekly, and no longer list a range of sessions. Program leadership will monitor treatment plans for the correct type and frequency of services during chart audits and/or staff supervision meetings. |