INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 26, 2017 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Gaudenzia Inc. Winner Co-occurring Woman & Children Program 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 (1) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
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Observations
Based on a physical plant inspection conducted June 26, 2017 between 11:00 am and 12:00 pm, it was observed that the facility failed to maintain all structures on the grounds of the facility so as to be free from any danger to health and safety as evidenced by the following:
1)The ceiling, between the two windows, of bedroom number 10 showed signs of an active leak, as it appears to be coming from the roof. The ceiling tile was wet and the paint below the tile was wet, peeling and bubbling from water.
The findings were reviewed with facility staff during the licensing inspection process.
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Plan of Correction
Bedroom #10 is closed for construction with work expected to be done by 8/1/2017.
Roof needs to be inspected and any open areas will be sealed.
Program Director will work with the Maintenance Department to stay within timeline. |
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.
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Observations
Based on the review of 7 client records, the facility failed to document informed and voluntary consent to release information forms prior to the disclosure of information in client record numbers 1, 2, 3, and 4.
Client #1 was admitted on 11/29/16 and was discharged on 6/9/17. There was documentation that urinalysis tests were conducted and the results were received; however, there was no proper consent to release information form signed by the client prior to disclosure.
Client #2 was admitted on 5/6/16 and was discharged on 2/10/17. There was documentation that urinalysis tests were conducted and the results were received; however, there was no proper consent to release information form signed by the client prior to disclosure.
Client #3 was admitted on 1/27/17 and was discharged on 3/20/17. There was documentation that urinalysis tests were conducted and the results were received; however, there was no proper consent to release information form signed by the client prior to disclosure.
Client #4 was admitted on 6/13/16 and was discharged on 1/23/17. There was documentation that urinalysis tests were conducted and the results were received; however, there was no proper consent to release information form signed by the client prior to disclosure.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Program Director has implemented the change as of 6/27/2017 and all clients at admission will sign a consent to release information for urinalysis testing. Program Director will review charts weekly for compliance. |