INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 10 & 11, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Inc. Winner Co-Occurring Women & 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 and a plan of correction is due on July 21, 2008.
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Plan of Correction
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705.10 (a) (1) (ii) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(ii) Maintain a minimum of two exits on every floor, including the basement, that are separated by a minimum distance of 15 feet.
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Observations
Based on a physical plant inspection conducted on June 11, 2008, the facility failed to ensure that exits were at least 15 feet apart.
Finding:
The internal stairwells from the second floor to the first floor run parallel to each other and are separated by a wall. The entrances to the exits are not more than 15 feet apart and the exits are not more than 15 feet apart.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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. The consent shall be in writing and include, but not be limited to:
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Observations
Based upon a review of 5 client records on June 10 & 11, 2008, the facility failed to obtain informed consents to release information in 5 of 5 client records reviewed.
Five of five records reviewed contained medical release forms that stated the information would be released to a laboratory of the facility ' s choice. This would not meet the requirements for an informed consent.
One of five records reviewed, #3, contained a release of information to Conwell Middle school without a consent to release information from the client.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based upon a review of 5 client records on June 10 & 11, 2008, the facility failed to document the blood pressure, pulse and respiration on the physical examination in four of five client records reviewed, specifically #1, 3, 4 & 5.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 upon a review of five client records on June 10 & 11, 2008 three required that a discharge summary be completed. One of the three records reviewed, #3, lacked a discharge summary.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |