INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 16, 2016, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia, 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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705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on an inspection of the physical plant conducted on May 16, 2016, the facility failed to keep the grounds of the facility safe and in good repair.
The toilet seat for the toilet in the restroom next to the conference room was wobbly and not firmly anchored to the toilet.
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Plan of Correction
Based on an inspection of the physical plant conducted on May 16, 2016, the facility failed to keep the grounds of the facility safe and in good repair.
Gaudenzia Coatesville will replace the broken toilet seat and will monitor all bathrooms to maintain the facility and in good repair. The program director will be responsible for ensuring this takes place once, weekly. The toilet was replaced by maintenance worker on 6/6/16. |
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 facility documents conducted during the onsite inspection on May 16, 2016, 3 out of 9 client records reviewed did not have treatment plan updates completed every 60 days.
Client #3 was admitted for treatment on 11/24/2015, and was an active client at the time of the onsite inspection. The client had a treatment plan update completed on 02/18.2016, but the client's next treatment plan update was not completed until 05/05/2016.
Client #7 was admitted for treatment on 11/19/2016, and was an active client at the time of the onsite inspection. The client had a treatment plan update completed on 01/03/2016, but the client's next treatment plan update was not completed until 04/17/2016.
Client #8 was admitted for treatment on 01/28/2016, and was discharged on 05/02/2016. The client's individualized treatment plan was completed on 02/24/2016, but there was no documented treatment plan update completed for the client.
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Plan of Correction
Based on a review of facility documents conducted during the onsite inspection on May 16, 2016, 3 out of 9 client records reviewed did not have treatment plan updates completed every 60 days.
Clinicians will make use of the Due Date Form by 6/1/16, that will alert the clinicians as to when the update treatment plans are due. Clinicians will complete the update treatment plans in accordance to the 60 day timeframe. The clinical supervisor will monitor the timeliness of the plans on a bi-weekly basis to ensure that timeframes are maintained. |