INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 20, 2007 through August 21, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Fountain Springs 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 17, 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 this 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 fiscal year and every year after and will include activities and accomplishments for the previous FY. The person responsible will be the Director of Development. |
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. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a complete psychosocial evaluation in three of five client records reviewed, #2, 3 and 5. Psychosocial evaluations did not include clinical impressions to provide a composite picture of the client, address the client's problems/needs or the client's preferred coping mechanisms.
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Plan of Correction
The psychosocial evaluation will include clinical impressions and provide a composite picture of the client to include the coping mechanisms in order to address the clients problems/needs. The Clinical Supervisor will provide training to the clinical staff to detail how this is to be addressed and documented in the client file. The Clinical Supervisor will review psychosocials for QI Meetings monthly and weekly for clinical meetings to ensure compliance. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure that counseling services were provided according to the individual treatment plan. According to the treatment plans, group counseling was to be provided three times per week, however, group counseling was only documented as occurring one to two times per week in five of five client records reviewed, #1, 2, 3, 4 and 5.
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Plan of Correction
Group counseling will be provided to all clients three (3) times per week as documented in the treatment plans. If the client needs to miss a group counseling session due to a medical appointment or court appearance, etc., it will be documented on the Record of Service. The Clinical Supervisor will provide training to clinical staff to ensure compliance with this. The Clinical Supervisor will review monthly for QI Meeting. |
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 staff schedules and training documentation, the facility failed to provide a sufficient number of staff persons certified in CPR and trained in first aid during the project's hours of operation. Specifically, employee #8 was not certified in CPR and first aid until 8/13/07, but was the only staff person scheduled from 7:00 a.m. until 1:00 p.m. on 6/17/07 and from 10:00 p.m. until 11:00 p.m. on 6/25/07.
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Plan of Correction
Fountain Springs will ensure that during all hours of operation, at least one (1) staff person on duty will be certified in CPR & First Aid training in order to be in compliance with regulations. As of 8/20/07, all staff are CPR & First Aid certified.
The Clinical Supervisor completes the staff work schedule and thus will ensure that CPR & First Aid trained staff is on the schedule twenty-four (24) hours per day, seven (7) days per week. The Clinical Supervisor will also ensure that all new staff receives CPR or First Aid training in the first thirty (30) days of employment. The Clinical Supervisor will further ensure that the staff receives updated training in these areas when necessary in order to maintain compliance. In addition, the Program Director will oversee work schedules and training plans for all staff. |