INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 5-8, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Erie Inc. Corry Satellite Office 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 5, 2008.
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Plan of Correction
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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based upon a review of the facility's fire drill record on August 8, 2008 the facility failed to maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
Finding:
The exit route used was not documented in any of the fire drills conducted.
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Plan of Correction
A fire drill was conducted on 8/22/08 and the exit route used was documented. The Program Supervisor and Division Director will ensure that the monthly fire drills document which exit route is used. This will be reviewed monthly during the Safety and Safety Committee meeting and the Quality Improvement meeting. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based upon a review of the facility's fire drill record on August 8, 2008 the facility failed to prepare alternate exit routes to be used during fire drills.
Finding:
The exit route used was not documented in any of the fire drills conducted; therefore, it was not possible to determine if the facility had prepared and practiced using alternate exits.
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Plan of Correction
A fire drill was conducted on 8/22/08 and the exit route used was documented. The Program Supervisor and Division Director will ensure that the monthly fire drills document which exit route is used. This will be reviewed monthly during the Safety and Safety Committee meeting and the Quality Improvement meeting. |
709.22(e) 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:
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Observations
Based upon a review of the facility's 2006 - 2007 annual report and an interview with the facility director, both occurring on August 8, 2008, the facility failed to make the annual report for Gaudenzia Erie Inc. available to the public.
Finding:
The facility failed to advertise where and when the annual report would be available for public viewing.
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Plan of Correction
The Regional Director will ensure that Gaudenzia Erie is represented in the annual Gaudenzia Inc. report. He will continue to monitor this annually. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based upon a review of five client records on August 7, 2008 the facility failed to document the drug and alcohol history within the time frame of the third session as per the facility's policy in two of five records reviewed.
Finding:
Client #1 was admitted on May 1, 2008 and did not have a completed drug and alcohol history until the eighth session on July 16, 2008.
Client #2 was admitted on June 10, 2008 and still had not had a completed drug and alcohol history in their file as of the review date for this inspection on August 7, 2008.
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Plan of Correction
Division Director met with clinical staff to review agency time frames for the clinical documentation. Program Supervisor will audit clinical files monthly to ensure compliance with agency time frames. The outcome of these audits will also be reviewed with the Division Director during the monthly Quality Improvement meetings. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based upon a review of five client records on August 7, 2008, the facility failed to document the personal history within the time frame of the third session as per the facility's policy in two of five records reviewed.
Finding:
Client #1 was admitted on May 1, 2008 and did not have a completed personal history until the eighth session on July 16, 2008.
Client #2 was admitted on June 10, 2008 and still had not had a completed personal history in their file as of the review date for this inspection on August 7, 2008.
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Plan of Correction
Division Director met with clinical staff to review agency time frames for the clinical documentation. Program Supervisor will audit clinical files monthly to ensure compliance with agency time frames. The outcome of these audits will also be reviewed with the Division Director during the monthly Quality Improvement meetings. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based upon a review of five client records on August 7, 2008 the facility failed to complete the psychosocial evaluation within the time frame of the third session as per the facility's policy in two of five records reviewed.
Findings:
Client #1 was admitted on May 1, 2008 and did not have a completed psychosocial evaluation until the eighth session on July 16, 2008.
Client #2 was admitted on June 10, 2008 and their fourth individual session was on July 31, 2008. As of the review date for this inspection, August 7, 2008, there still was not a completed psychosocial evaluation in the file.
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Plan of Correction
Division Director met with clinical staff to review agency time frames for the clinical documentation. Program Supervisor will audit clinical files monthly to ensure compliance with agency time frames. The outcome of these audits will also be reviewed with the Division Director during the monthly Quality Improvement meetings. |
709.92(a) 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:
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Observations
Based upon a review of five client records on August 7, 2008 the facility failed to complete the individual treatment and rehabilitation plan within the time frame of the fourth session as per the facility's policy in two of five records reviewed.
Findings:
Client #1 was admitted on May 1, 2008 and did not have a completed individualized treatment plan until the eighth session on July 16, 2008.
Client #2 was admitted on June 10, 2008 and their fourth individual session was on July 31, 2008. As of the review date for this inspection, August 7, 2008, there still was not a completed individual treatment and rehabilitation plan in the file.
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Plan of Correction
Division Director met with clinical staff to review agency time frames for the clinical documentation. Program Supervisor will audit clinical files monthly to ensure compliance with agency time frames. The outcome of these audits will also be reviewed with the Division Director during the monthly Quality Improvement meetings. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based upon a review of five client records on August 7, 2008, one record required that a follow up be conducted. The facility failed to complete the follow up within seven days as per the facility's policy.
Finding:
Client #3 was discharged on June 24, 2008 and the follow up had not been conducted until July 8, 2008.
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Plan of Correction
Division Director met with Administrative Coordinator about agency time frames in regards to client follow-up. Program Supervisor will ensure that policy time frames are being followed and continue to be followed. |