Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site, at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 1, an abbreviated off-site inspection, conducted on August 27, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.
Based on the findings of Part 1, an abbreviated off-site inspection, Gaudenzia Erie, Inc. 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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Observations
A review of the November 2019 through July 2020 fire drill logs was conducted on August 27, 2020 during Part 1 of the annual licensing inspection. The facility failed to conduct a fire drill during sleeping hours for the months that were reviewed. The last sleeping fire drill, according to the fire drill log, was conducted on September 22, 2019.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As per discussion with DDAP on 8/27/20
sleeping hours have been redefined from the original 11p-0800am to 12am to 0630am to more effectively capture the nocturnal fire drill data needed for compliance.
Compliance will be obtained by:
Addendum to client handbook noting time change
Information dissemination in staff meeting
Direct memos to Program Director, Clinical Supervisor and HM supervisor with implementation and compliance achieved by 10/1/20 as evidenced by a nocturnal fire drill conducted only from 12a to 0600am. Times of nocturnal fire drills will be monitored during PI to ensure drills are being completed during 12am-0630am to ensure compliance. |