INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 10, 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 Coal Township 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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705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on a physical plant inspection the facility failed to ensure that all trash was stored in a covered container as evidenced by the facility ' s dumpster lid kept open.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The cover to the dumpster was bent by a bear and unable to be closed. The organization has a new waste management vendor, which will be replacing the current dumpster with a bear-proof dumpster. In the meantime, an attempt will be made to bend the cover enough to be able to close it. Once the dumpster is replaced, the Program Director will ensure compliance with regulation 705.2 (4) by posting a sign stating that the dumpster lid is to be kept closed at all times. The Program Director will hold a mandatory staff meeting on June 17, 2021 to discuss the proper maintenance of the trash dumpsters. In addition, the trash dumpster area will be added to the staff house run sheet for daily checks to ensure that the area is secure. House run sheets will be reviewed weekly by the Clinical Supervisor. Additionally, the Regional Quality Assurance manager will conduct quarterly site visits to ensure compliance; this visit will be documented in the quarterly CQI report. The Compliance department will conduct at least annual reviews to ensure implementation of the POC. |
709.93(a)(11) LICENSURE Client records
709.93. 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:
(11) Follow-up information.
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Observations
Based on a review of five applicable client records, the facility failed to ensure that two closed records included follow up information.
Client#6 was admitted on October 27, 2020 and was discharged on March 1, 2021.
Client#7 was admitted on August 19, 2020 and was discharged on March 23, 2021.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
An all staff meeting will be held on May 21, 2021 to address clinical staff on treatment management procedures specific to assuring that follow up is to be completed for every type of discharge. Management staff reviewed the most efficient process and determined that the follow up will be completed by the assigned clinical staff and submitted as part of the discharge documentation process. The Clinical Supervisor will review for compliance during the monthly internal CQI process. Clinical staff will be monitored monthly in regular supervisory sessions. Additionally, the Regional Quality Assurance department will conduct quarterly audits to ensure compliance; this audit will be documented in the quarterly CQI report. The compliance department will conduct annual reviews to ensure continued implementation of all action items on the corrective action plan. |