INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 20 - 24, 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 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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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to document fire extinguisher training was completed upon staff employment in one of two personnel records.
Employee # 5 was hired May 10, 2021. Fire extinguisher training was not documented until August 19, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This staff member has since completed the Fire Extinguisher training on 8/19/2021.
Going forward, staff will complete all required trainings within the required timeframes. This will be monitored by the Program Director on at least a quarterly basis through review of staff training files.
Additionally, the Compliance department will conduct a review of all Plans of Correction within 9 months to ensure full implementation.
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705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to document all personnel on all shifts were trained to perform assigned tasks during emergencies in one of two personnel records.
Employee # 5 was hired May 10, 2021. Emergency training was not documented for employee # 5 upon employment for their assigned shift.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This staff member has since completed the emergency procedures training on 8/19/2021.
Going forward, staff will complete all required trainings within the required timeframes. This will be monitored by the Program Director on at least a quarterly basis through review of staff training files.
Additionally, the Compliance department will conduct a review of all Plans of Correction within 9 months to ensure full implementation.
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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 a treatment plan review and update at least every sixty days in two of five client records.
Client # 1 was admitted February 5, 2021 and discharged August 24, 2021. The individual treatment plan was completed February 19, 2021. Treatment plan updates were documented April 27, 2021 and June 22, 2021.
Client # 6 was admitted April 17, 2021. The individual treatment plan was completed April 24, 2021. Treatment plan updates were documented June 26, 2021 and September 7, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff have been trained on documenting treatment plans reviews and the frequency requirements. A review of this training will occur on 10/29/2021.
The Program Director will monitor to ensure compliance through monthly audits of clinical records, and follow up on any inconsistencies in clinical supervision sessions.
The Quality Assurance department will conduct quarterly program review, and the Compliance department will review the plan of correction at least annually to ensure implementation.
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