INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 9, 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. 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) (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 a review of client records, the project failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in two of seven client records reviewed.
Client #1 was admitted on December 29, 2020 and was an active client at the time of the inspection. A release of information form to the funding source, signed and dated by the client on December 29, 2020, allowed for the release of psychological/psychiatric evaluations, treatment plan, case consultations, mental health records, discharge summary, medication records and assessments, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #7 was admitted on December 30, 2020 and was discharged on May 2, 2021. A release of information form to the funding source, signed and dated by the client on December 30, 2020, allowed for the release of psychological/psychiatric evaluations, treatment plan, case consultations, mental health records, discharge summary, medication records and assessments, all of which exceeds the limits established by 4 Pa. Code 255.5.
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
Program received a citation for failing to keep disclosures within the established guidelines of 4 PA Code 255.5 during last year's licensure renewal inspection in October 2020. As a means to rectify this deficiency, Program Administrative and Clinical staff attended an in-service training in October 2020 and attended DDAP's Confidentiality Training (online) during that same month. Furthermore, Program Director monitored the consent forms during monthly audits. While Program did receive a repeat citation for this area, it is believed that program was making significant progress towards eradicating the presence of any consent forms exceeding the limits established by 4 PA code 255.5, which was evidenced by an overall decrease in the amount of deficient charts (7 out of 7 in 2020 compared to 2 out of 7 in 2021).
To this end, program is going to utilize the above-mentioned plan of correction as a foundation and has built onto it in the following ways. As of Jan 2021, the Release of Information form has been revised to ensure that releases follow PA 255.5. In addition, Program Administrative and Clinical Staff are scheduled to attend a Region-Wide Release of Information (Confidentiality) In-service on 7/23/2021. Furthermore, all Program Administrative and Clinical Staff will be attend the Practical Applications of Confidentiality Training (DDAP) by October 1, 2021 (pending training availability).
Program Director will monitor releases of information during monthly internal audits and the assigned Quality Assurance Manager will monitor these documents during quarterly file audits.
Finally, to address the identified deficiencies in the client files identified, the release of information for Client #1 has been updated as of 4/1/21. Client #7 has been discharged and program is unable to update this consent form.
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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 on an individual that included case consultation notes in four of seven client records reviewed.
Client #1 was admitted on December 29, 2020 and was an active client at the time of the inspection. There were no case consultation notes documented in the client record at the time of the inspection.
Client #4 was admitted on November 11, 2020 and was discharged on December 9, 20202. There were no case consultation notes documented in the client record at the time of the inspection.
Client #6 was admitted on November 2020 and was discharged on February 18, 2021. There were no case consultation notes documented in the client record at the time of the inspection.
Client #7 was admitted on December 30, 2020 and was discharged on May 2, 2021. There were no case consultation notes documented in the client record at the time of the inspection.
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
Program received a citation for failing to ensure that the records contain a case consultation notes during last year's licensure renewal inspection in October 2020. As a means to rectify this deficiency, Program Clinical staff attended an in-service training in October 2020 geared around Clinical/Recordkeeping Guidelines/Expectations, which included Case Consultations. In addition to this, Program Director monitored the presence of case consultation notes on a monthly basis. While this plan of correction is believed to be viable start, the repeat deficiency seems to indicate that more deliberate action and focused follow-up is needed.
Program Director will conduct an in-service training with Clinical Staff to review the agency-wide workflow, which includes, but is not limited to, Case Consultation notes, on 7/19/2021. In addition to this, Program Director has developed an internal checklist to monitor the presence of the required case consultation notes, which is completed on a monthly basis. Any identified missing Case Consultation notes will be required to be completed within established guidelines/expectations. Finally, Quality Assurance Manager will monitor these documents during quarterly file audits. |
709.53(a)(9) LICENSURE Aftercare plans
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:
(9) Aftercare plan, if applicable.
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Observations
Based on the review of client records, the project failed to document a complete client record on an individual that included an aftercare plan in three of seven client records reviewed.
Client #4 was admitted on November 11, 2020 and was discharged on December 9, 20202. There was no aftercare plan documented in the client record at the time of the inspection.
Client #6 was admitted on November 2020 and was discharged on February 18, 2021. There was no aftercare plan documented in the client record at the time of the inspection.
Client #7 was admitted on December 30, 2020 and was discharged on May 2, 2021. There was no aftercare plan documented in the client record at the time of the inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Program Director will conduct an in-service training with Clinical Staff to review the agency-wide workflow, which includes, but is not limited to, Aftercare plans, on 7/19/2021. In addition to this, Program Director has developed an internal checklist to monitor the presence of the required aftercare plans, which is completed on a monthly basis. Any identified missing Aftercare plans will be required to be completed within established guidelines/expectations. Finally, Quality Assurance Manager will monitor these documents during quarterly file audits.
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709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based on the review of client records, the project failed to document a complete client record on an individual that included a discharge summary in three of seven client records reviewed.
Client #4 was admitted on November 11, 2020 and was discharged on December 9, 20202. There was no discharge summary documented in the client record at the time of the inspection.
Client #6 was admitted on November 2020 and was discharged on February 18, 2021. There was no discharge summary documented in the client record at the time of the inspection.
Client #7 was admitted on December 30, 2020 and was discharged on May 2, 2021. There was no discharge summary documented in the client record at the time of the inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Program Director will conduct an in-service training with Clinical Staff to review the agency-wide workflow, which includes, but is not limited to, Discharge Summaries, on 7/19/2021. In addition to this, Program Director has developed an internal checklist to monitor the presence of the required discharge summaries, which is completed on a monthly basis. Any identified missing Discharge summaries will be required to be completed within established guidelines/expectations. Finally, Quality Assurance Manager will monitor these documents during quarterly file audits. |