INITIAL COMMENTS
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This report is a result of an on-site licensure inspection conducted on May 7, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia, Inc. Re-Entry 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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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 obtain an informed and voluntary consent to release client information form in three of eight client records reviewed.
The findings include:
Eight client records were reviewed for documentation of informed and voluntary consent to release client information forms on May 7, 2014. The facility failed to obtain an informed and voluntary consent to release client information form in client record # 2, 3, and 4.
Client # 2 was admitted to the program on 1/16/14 and was still an active client as of 5/7/14. The facility failed to obtain an informed and voluntary consent for the release of client information to a government agency. Per progress note on 3/5/14, 3/25/14, and 4/14/14 a government official was on-site to visit the client and requested a copy of the client's psychiatric evaluation. In addition, the facility faxed client # 2's psychiatric evaluation on 4/17/14 without obtaining a valid consent to release client information form.
Client # 3 was admitted to the program on 3/14/14 and was still an active client as of 5/7/14. The facility failed to document 9 consent to release client information forms that complied with 28 Pa. Code Client # 3 signed (9) consent to release forms to various agencies; however, the facility failed to obtain the dated signature of a witness.
Client # 4 was admitted to the program on 2/24/14 and was still an active client as of 5/7/14. The facility failed to document an informed and voluntary consent for the release of client information to a government entity. The facility faxed client information/letter to a government entity on 2/25/14 and 3/5/14 without obtaining a valid consent to release information form from client # 4.
The Facility Director confirmed the findings.
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Plan of Correction
Clinical Supervisor, Kim Douglass, will have a Clinical Team Meeting (no later than 6/30/14) where she will review the importance of obtaining consents to release and obtain to any and all external contacts (both offical govnment agents and personal contacts). Clinical Supervisor will enforce this policy. Staff members who have violated this will be schedule to retake the Confidentiality training.
Regional Deputy (Gail Hannah) will oversee that this process is completed while the Program Director (Jonathan Lewis) is out of FMLA - He will assume this responsibility for oversight of compliance upon his return. |
709.53(a) LICENSURE Complete Client Record
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:
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Observations
Based on a review of client records, the facility failed to document a complete client record in three of eight client records reviewed.
The findings include:
Eight client records were reviewed on May 7, 2014. The facility failed to document a complete client record that included a record of services provided in client record # 1, and failed to document that work done by the client is an integral part of the treatment and rehabilitation plan in client records # 1, 5 and 7. The facility also failed to document a complete and legible medication record for the month of May for client # 5.
Client # 5 was prescribed: 300 mg of Lithium three times daily at 8AM, 1PM, and 5PM and 25 mg of Metoprolol twice daily at 8 AM and 10 PM. The Medication Administration Record (MAR) was not legible and some days were left blank; therefore it was unclear if client # 5 took the medication as prescribed from 5/1/14 to 5/7/14.
The Facility Director confirmed the findings.
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Plan of Correction
Clinical Supervisor will meet with Clinical Staff & House Managers prior 6/30/14 to review all aspects of a complete chart and how to properly document the MAR sheet - including when a member refuses or skips medication. Also the work rehabilitation/work therapy must be documented in the chart. She will ensure that all staff are clear that all documentation must be legible. Lastly, any clinical staff who has not yet attended the revised Clinical Record Keeping and Current Standards Training, must attended the next scheduled training event. Regional Deputy (Gail Hannah) will oversee this to ensure compliance with this plan of correction. |