INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 16, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia at Sunbury 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 14, 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
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 FY 07 will be
printed and available to the public for the current FY and every year thereafter and will include activities and accomplishments for the previous fiscal year. The person responsible will be the 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
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
Action Steps and timelines will be written during September for the '07 fiscal year as well as revised goals and objectives for the 08 fiscal year along with corresponding action steps and timelines.
Executive staff who are responsible for specific goal areas will develop and revise plans in specific goal areas in consultation with their respective Board Committees and available resources for approval at the September Board Meeting and every September thereafter.
Persons responsible - Executive Staff.
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709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
The facility failed to include proposed types of support services on the individual treatment plans in five of ten client records reviewed, #1, 4, 7, 13 and 14.
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Plan of Correction
All individual treatment plans will include types of support service, namely, AA, NA and/or Double Trouble or other specific recovery support meetings. Program Supervisor will provide an inservice to clinical staff to ensure compliance with this.
Completion Date: 9-4-07
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
The facility failed to review and update treatment plans every 60 days in five of ten client records reviewed, #2, 6, 7, 8 and 14.
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Plan of Correction
All active client files will have treatment plans reviewed and updated every 60 days. Program Supervisor will provide training to clinical staff to ensure compliance with this. Program Supervisor will also review updated treatment plans for timeliness through the monthly QI meeting as well as weekly during clinical meetings and supervision.
Completion Date 9-4-07
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709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
The facility failed to include goals with time frames on the aftercare plan in three of three client records reviewed, #9, 11 and 14.
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Plan of Correction
All aftercare plans will include time frames for goals. Program Supervisor will provide training to clinical staff to ensure compliance with this. Program Supervisor will also review aftercare plans for timeliness through the monthly QI meeting as well as weekly during clinical meetings and supervision.
Completion Date 9-4-07
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