INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 5-8, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Erie Inc. Girard Satellite Office 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 and a plan of correction is due on September 25, 2008.
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Plan of Correction
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704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based upon a review of the facility staffing form and an interview with staff person #2 on August 8, 2008, the facility failed to ensure that the full-time equivalent (FTE) counselor caseload for counseling in outpatient programs did not exceed 35 active clients.
Findings:
The FTE caseload was at 57:1.
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Plan of Correction
Program Supervisor will review census daily to ensure that Gaudenzia Erie follows the 35:1 counselor to client ratio. Division Director will oversee the department to also ensure that this ratio is followed. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based upon a review of the facility's fire drill record on August 8, 2008, the facility failed to maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
Finding:
The exit route used was not documented in the fire drill log for any of the fire drills conducted.
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Plan of Correction
A fire drill was conducted on 8/26/08 and the exit route was documented. The Program Supervisor and Division Director will ensure that the monthly fire drills document which exit route is used. This will be reviewed monthly during the Safety and Sanitation Committee meetings and the monthly Quality Improvement meeting. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based upon a review of the facility's fire drill record on August 8, 2008, the facility failed to prepare alternate exit routes to be used during fire drills.
Finding:
The exit route used was not documented in any of the fire drills conducted; therefore, it was not possible to determine if the facility had prepared and practiced using alternate exits.
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Plan of Correction
A fire drill was conducted on 8/26/08 and the exit route used was documented. The Program Supervisor and Division Director will ensure that the monthly fire drills document which exit route is used. This will be reviewed monthly during the Safety and Sanitation Committee meeting and the Quality Improvement meeting. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based upon a review of the facility's 2006 - 2007 annual report and an interview with the facility director, both occurring on August 8, 2008, the facility failed to make the general public aware of the availability of the annual report for Gaudenzia Erie Inc.
The findings were:
The facility lacked documentation to verify that they made the general public aware of the availability of the annual report for the year ended June 20, 2007.
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Plan of Correction
The Regional Director will ensure that Gaudenzia Erie is represented in the annual Gaudenzia Inc. report. He will continue to monitor this annually. |
709.91(b)(2)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(ii) Hours of operation.
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Observations
Based upon a review of four client records on August 7, 2008 three were reviewed for the client's Drug and Alcohol histories. The facility failed to document the drug and alcohol history within the time frame of the third session as per the facility's policy in one of three records reviewed.
Finding:
Client #1 was admitted on April 7, 2008 and did not have a completed drug and alcohol history until the fourth session on May 5, 2008.
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Plan of Correction
Division Director met with clinical staff to review agency time frames for the completion of clinical documentation which includes the drug and alcohol histories. Program Supervisor will audit clinical files monthly to ensure compliance with agency time frames. The outcome of these audits will also be reviewed with the Division Director during monthly Quality Improvement meetings. |
709.91(b)(2)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iii) Fee schedule.
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Observations
Based upon a review of four client records on August 7, 2008 three were reviewed for the client's Personal Histories. The facility failed to document the personal history within the time frame of the third session as per the facility's policy in one of three records reviewed. The facility also failed to document the military history in three of three records reviewed.
Finding:
Client #1 was admitted on April 7, 2008 and did not have a completed personal history until the fourth session on May 5, 2008.
Client records #1-3 did not have any documentation regarding the clients' military history.
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Plan of Correction
Division Director met with clinical staff to review agency time frames for the completion of clinical documentation which includes the personal history to include military history. Program Supervisor will audit clinical files monthly to ensure compliance with agency time frames and completion of the documents. The outcome of these audits will also be reviewed with the Division Director during monthly Quality Improvement meetings. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based upon a review of four client records on August 7, 2008 three were reviewed for the client's Psychosocial Evaluation. The facility failed to document the psychosocial evaluation within the time frame of the third session as per the facility's policy in one of three records reviewed.
Finding:
Client #1 was admitted on April 7, 2008 and did not have a completed psychosocial evaluation until the fourth session on May 5, 2008.
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Plan of Correction
Division Director met with clinical staff to review agency time frames for the completion of clinical documentation which includes the psychosocial evaluation. Program Supervisor will audit clinical files monthly to ensure compliance with agency time frames and completion of the documents. The outcome of these audits will also be reviewed with the Division Director during monthly Quality Improvement meetings. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based upon a review of four client records on August 7, 2008 three were reviewed for the client's Individualized Treatment Plan. The facility failed to document the individualized treatment plan within the time frame of the third session as per the facility's policy in one of three records reviewed.
Finding:
Client #1 was admitted on April 7, 2008 and did not have a completed drug and alcohol history until the fourth session on May 5, 2008.
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Plan of Correction
Division Director met with clinical staff to review agency time frames for the completion of clinical documentation which includes individual treatment plans. Program Supervisor will audit clinical files monthly to ensure compliance with agency time frames and completion of the documents. The outcome of these audits will also be reviewed with the Division Director during monthly Quality Improvement meetings. |