INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 4, 2007 through September 5, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Vantage 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 and a plan of correction is due on September 28, 2007.
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Plan of Correction
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709.22(e)(1) 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:
(1) Activities and accomplishments of the preceding year.
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Observations
Based on a review of administrative documentation, the facility failed to include activities and accomplishments of the preceding year for the facility in the 2005-2006 annual report.
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Plan of Correction
The annual report for the FY'07 will be printed and available for the current FY and every year thereafter and will include activities and accomplishments for the previous FY.
Person Responsible:
Director of Development
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709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
Based on a review of administrative documentation, the project failed to include time frames and available resources for the 2007-2008 project goals and objectives.
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Plan of Correction
Executive Staff who are responsible for specific goal areas will develop and revise plans in specific goals areas in consultation with their respective Board Committees and available resources for approval at the September Board meeting and every September thereafter.
Person Responsible:
Executive Staff
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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 on a review of client records, the facility failed to obtain an informed and voluntary consent from the client to disclose information to the funding source in two of six client records reviewed, #4 and 6.
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Plan of Correction
The facility will obtain an informed and voluntary consent from every client to disclose information to the funding source.
In addition, on September 25, 2007, all staff who work with clinical paperwork, to include the release of information, will be attending a paperwork training scheduled at the facility. This training will cover the purpose of a release of information and how to fill one out correctly.
Person Responsible:
Administrative
Coordinator
Person Responsible for Monitoring: Clinical Supervisor and Program Director
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705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on a physical plant inspection, the facility failed to ensure that one bathroom had an operable exhaust fan.
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Plan of Correction
The ladies bathroom exhaust fan has been repaired. It is the responsibility of the house managers to ensure that all bathrooms have an operable exhaust fan. All exhaust fans will be maintained and remain operable.
Person(s) Responsible: House Managers
Person Responsible for Monitoring: Program Director
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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of employee certifications and the staff schedule, the facility failed to ensure that at least one person trained in these skills was on site during the hours of operation. Employee #5 does not have CPR certification and first aid training. Employee #5 was scheduled to work from 3:00 PM until 11:00 PM on 7/29/07 with another employee who was also missing CPR certification and first aid training. Employee #5 was also scheduled as the sole staff person on duty from 8:00 PM until 11:00 PM on 8/26/07.
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Plan of Correction
The two staff members who require CPR/First Aid Certification will obtain their training on October 9, 2007. The Administrative Coordinator will be responsible to register all new staff to be trained in CPR/First Aid.
The Clinical Supervisor will not schedule any staff to work on there own who has not received CPR/First Aid training.
The Administrative Coordinator will schedule staff to attend CPR prior to their certification expiring.
Person Responsible:
Administrative Coordinator
Person Responsible for Monitoring: Program Director
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