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 2, an abbreviated on-site inspection, conducted on October 2, 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 were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated 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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705.7 (b) (3) 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:
(3) Clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
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Observations
The facility failed to ensure that all eating, drinking and cooking utensils and all food preparation areas were cleaned after each usage. Based on the physical plant inspection, conducted on October 2, 2020, several plates of food were stacked on the counter and were not cleaned after usage.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An in-service training was held with all Operational Staff on October 29, 2020 on the topic of food service. This training focused on facility, licensing, and generally accepting food safety/sanitation guidelines, which included but was not limited to, proper storage of food after meals.
Finally, House Manager Supervisor and Program Director will ensure that all Operational Staff are adhering to these expectations by monitoring the system/timeframes in place to ensure the proper storage/cleanliness of the food prep/storage areas.
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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
The facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in seven of seven client records reviewed.
Client #1 was admitted on April 28, 2020 and was still active at the time of inspection. A release of information form to the funding source was signed and dated by the client on April 28, 2020 that allowed for the release of psychological and psychiatric evaluations, treatment plans, case consults, mental health records, physical and medical records, discharge summary, progress notes, medication records and assessments, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #2 was admitted on July 20, 2020 and was still active at the time of inspection. Release of information forms to the funding source and a probation officer, both signed and dated by the client on July 20, 2020, that allowed for the release of psychological and psychiatric evaluations, treatment plans, case consults, mental health records, physical and medical records, discharge summary, progress notes, medication records and assessments, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #3 was admitted on June 3, 2020 and was still active at the time of inspection. A release of information form to the funding source was signed and dated by the client on June 3, 2020 that allowed for the release of psychological and psychiatric evaluations, treatment plans, case consults, mental health records, physical and medical records, discharge summary, progress notes, medication records and assessments, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #4 was admitted on August 5, 2019 and was discharged on November 4, 2019. A release of information form to the funding source was signed and dated by the client on August 5, 2019 that allowed for the release of psychological and psychiatric evaluations, treatment plans, case consults, mental health records, physical and medical records, discharge summary, progress notes, medication records and assessments, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #5 was admitted on January 24, 2020 and was discharged on November 4, 2019. A release of information form to the funding source was signed and dated by the client on January 24, 2020 that allowed for the release of psychological and psychiatric evaluations, treatment plans, case consults, mental health records, physical and medical records, discharge summary, progress notes, medication records and assessments, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #6 was admitted on January 14, 2020 and was discharged on June 15, 2020. Release of information forms to the funding source and probation agency, both signed and dated by the client on January 14, 2020, that allowed for the release of psychological and psychiatric evaluations, treatment plans, case consults, mental health records, physical and medical records, discharge summary, progress notes, medication records and assessments, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #7 was admitted on June 15, 2020 and was discharged on August 18, 2020. A release of information form to the funding source was signed and dated by the client on June 15, 2020 that allowed for the release of psychological and psychiatric evaluations, treatment plans, case consults, mental health records, physical and medical records, discharge summary, progress notes, medication records and assessments, all of which exceeds the limits established by 4 Pa. Code 255.5.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An In-Service Training was conducted with all Clinical/Administrative Staff on October 23, 2020 geared around Informed and Voluntary Consents to Release Information. Emphasis was placed on educating and/or re-educating staff about ensuring that these consents are completed in accordance with State and Federal Confidentiality guidelines. In addition to this, all
Clinical/Administrative staff completed or re-completed DDAP's Confidentiality Training through Train PA. Finally, Program will be scheduling all Clinical/Administrative Staff to complete or re-complete the Practical Applications of Confidentiality (based on course availability).
Furthermore, during routine audits/review of electronic health records, Program Director will ensure that all records contain the consents to release information to all entities and that all consents are completed in accordance with State and Federal Confidentiality guidelines.
Finally, for all current clients, Program Director and Administrative Assistant will redo the consent forms, in accordance with PA State Confidentiality Laws/Guidelines, limiting disclosure to the five permitted areas ("Big 5"). Program Director will make a notation on the current consent forms to denote that they are/have been redone.
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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
The project failed to ensure that all unusual incident reports, that involve ambulance personnel being onsite, were reported to the Department within 3 business days. Based on a client record review, Client #5's record documented that there was an incident that required the involvement of ambulance personnel on April 14, 2020. There was no documentation presented indicating that the incident was reproted to the Department at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will review all unusual incidents with staff on a weekly basis to ensure communication of incidents. If an unusual incident report is deemed necessary, as outlined/defined by licensing guidelines, Program will ensure that all necessary reports are submitted to the Department within the requested timeframe. Program Director will be the one responsible party that will ensure completion of the report. |
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
The facility failed to ensure that there was a complete client record on an individual's involvement with the project, which it to include case consultation notes in three of seven client records reviewed.
Client #1 was admitted on April 28, 2020 and was a current client at the time of the inspection. There was no documentation of case consultation notes in the client's record.
Client #3 was admitted on June 3, 2020 and was a current client at the time of the inspection. There was no documentation of case consultation notes in the client's record.
Client #7 was admitted on June 15, 2020 and was discharged on August 18, 2020. There was no documentation of case consultation notes in the client's record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An In-Service Training was conducted with all Clinical Staff on October 23, 2020 geared around Clinical Recordkeeping Guidelines/Expectations. Emphasis was placed on reviewing Clinical Recordkeeping Guidelines, Timeframes, and Expectations, especially as it related to completion of case consultation notes.
Furthermore, during routine audits/review of electronic health records, Program Director will ensure that all records include case consultation notes that meet, and/or exceed, the services prescribed on an individual's treatment plan (s) as well as, licensing guidelines.
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