INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on December 6-9, 2011, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Gaudenzia Erie Inc - Edinboro 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.
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Plan of Correction
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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 on a review of the fire drill logs, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings include:
A review of the fire drill logs for the period of July 2011 through November 2011 were reviewed on December 6, 2011. Fire drills were completed on 11/9/11, 10/19/11, 9/28/11, 8/17/11 and 7/20/11. The exit route used during the July and August 2011 fire drills was the main exit/entrance. The fire drills that took place in November, October, and September 2011 did not indicate which exit/entrance was used for the fire drill.
An interview with the clinical supervisor took place on December 6, 2011. The aforementioned information was confirmed.
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Plan of Correction
Program Director of Outpatient Services will review fire drill procedures with staffing including documentation of use of alternative exits. This has been added on to the fire drill documentation page. This will be reviewed monthly in UR/QI meeting. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document a preliminary treatment plan as per agency policy in two of four client records.
The findings include:
Four complete outpatient client records were reviewed on December 8, 2011. A preliminary treatment plan, per agency policy, is to be completed at the time of first contact/session with the counselor. The facility failed to document a preliminary treatment plan at the time of first contact/session with the counselor in two of four client records.
Client #3 was admitted to outpatient treatment on July 20, 2011 and the admission session took place on that date. The preliminary treatment plan was due to be completed on July 20, 2011. The preliminary treatment plan was completed on July 27, 2011.
Client #4 was admitted to outpatient treatment on September 28, 2011 and the admission session took place on that date. The preliminary treatment plan was due to be completed by September 28, 2011. The preliminary treatment plan was completed on November 2, 2011.
An interview took place with the clinical supervisor on December 8, 2011. The completion dates for the preliminary treatment plans were confirmed as listed above.
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Plan of Correction
Program Director of Outpatient will review/train staff on agency policies in regards to time frames of documentation of preliminary treatment plans. Training will be completed on 1/27/12 and will be monitored by the Program Director during UR/QI process |