INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 7, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gaudenzia West Shore 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:
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Plan of Correction
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705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on a physical plant inspection on June 7, 2021, the facility failed to keep all exits from rooms unobstructed.
The emergency exit door located in the conference room was locked with a dead bolt during the licensing inspection.
These finding were reviewed with the facility staff during the licensing process.
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Plan of Correction
Division Director will submit a work order on June 11th, 2021, through the maintenance department to request the Regional Plant Manager remove the deadbolt from the door and replace it with a cover to avoid further instances where it could be locked while the building is occupied. The work order will request that completion of request is done no later than June 30th, 2021.
On June 11th, 2021, Division Director sent an email to the staff at the program, explaining that locking the deadbolt was not necessary. Division Director or Clinical Supervisor will check this each day the office is open and document it until the deadbolt has been removed.
Facility's monthly safety reports will include unannounced fire drills. This will allow the program to ensure that all exits are clear and able to be used. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility ' s fire drill log from July 2020 through April 2021, the facility failed to conduct an unannounced fire drill in the months of November 2020, January 2021, February 2021 and March of 2021.
These finding were reviewed with the facility staff during the licensing process.
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Plan of Correction
On June 11th, 2021, Division Director met with Administrative Assistant to review the standards for Fire Drills. The meeting was documented and signed by both the Division Director and Administrative Assistant for verification and acknowledgement.
Beginning July 2021, the Administrative Assistant will copy Division Director when submitting monthly safety reports so that Division Director can review the reports for accuracy and address any missing items.
Facility will conduct monthly fire drill and document on the fire drill log.
The Administrative Assistant will be asked to do this ongoing. |
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
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in three out of six records reviewed.
Client #2 was admitted on January 6, 2021 and was still active at the time of the inspection. A comprehensive treatment plan was completed on January 14, 2021 and the next update was due no later than March 15, 2021; however, the updated treatment plan was completed on April 9, 2021.
Client #3 was admitted on October 7, 2020 and was still active at the time of the inspection. A treatment plan update was completed on February 4, 2021 and the next update was due no later than April 5, 2021; however, there was no update documented in the record at the time of the inspection.
Client #6 was admitted on September 18, 2020 and was still active at the time of the inspection. A treatment plan update was completed on February 18, 2021 and the next update was due no later than April 18, 2021; however, the updated treatment plan was completed on May 13, 2021.
These finding were reviewed with the facility staff during the licensing process.
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Plan of Correction
On June 25, 2021, Clinical Supervisor will review treatment plan updates and regulatory timeframes per level of care with all counselors during weekly clinical meeting.
Beginning July 1, 2021 and ongoing, Clinical Supervisor will review treatment plan updates as part of their monthly chart audits. The Clinical Quality Manager of the Central Region will also audit charts quarterly throughout the year and look at treatment plan updates as part of their audit.
Completed chart audits will be reviewed with primary counselor and documented in supervision notes. Ongoing concerns will be addressed in supervision as well. |