INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the June 19, 2009 licensure renewal inspection. The follow-up inspection was conducted on November 17, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Gaudenzia Inc. Winner Co-Occurring Women and Children Program 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 December 18, 2009 .
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Plan of Correction
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705.10 (a) (1) (ii) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(ii) Maintain a minimum of two exits on every floor, including the basement, that are separated by a minimum distance of 15 feet.
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Observations
Based on an interview with the facility director the facility failed to ensure that exits were at least 15 feet apart.
Findings:
According to an interview with the facility director on November 17, 2009 at 2:30 p.m. the facility has yet to implement the plan of correction to correct this deficiency. The director did say that blue prints have been drawn up, however, no construction has begun to rectify the area of non-compliance. The internal stairwells from the second floor to the first floor and the third floor to the second floor run parallel to each other and are separated by a wall. The entrances to the exits are not more than 15 feet apart and the exits are not more than 15 feet apart.
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Plan of Correction
This was referred to the CFO for Gaudenzia at the Corporate Office. On april 28, 2010, the Department accepted the preliminary drawings previously submitted by Gaudenzia correcting the deficiency 705.10(s)(ii) and Gaudenzia accepting the conditions and stipulations aubmitted to Gaudenzia by the Department on March 9, 2010. Construction drawings bt the architect will take 30 days. The usual time frame for the approval of plans to obtain a building permit and the awarding of a construction contract will be 30 days. The actual construction is estimated to take 60 days. The entire project will take four to five months from May 1, 2010.
This makes the expected completion date to be October 31, 2010. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on the review of four client records which were reviewed for treatment plan updates, the facility failed to document an assessment of the client's progress in relationship to the stated goals of the prior treatment plan on the treatment plan update in four of four client records reviewed.
Findings:
Four client records were reviewed on November 17, 2009. An assessment of the client's progress in relationship to the stated goals of the prior treatment plan was required in four client records. The facility failed to document an assessment of the client's progress in relationship to the stated goals of the prior treatment plan in client records #1, 2, 3, and 4. Additionally, the facility failed to document treatment plan updates in record #4 that were due on 10/15/2009 and 11/15/2009.
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Plan of Correction
New Director began at Winner on 11/2/09. Since that time, the Director has been reviewing all treatment plans for effectiveness and completeness. In-service has been done by the Director with the Counselor III and the Clinical Supervisor. In-service was held on November 30, 2009. Clinical Supervisor will be reviewing charts weekly to insure compliance with weekly clinical documentation requirements. Director will be doing chart audits for the next six months to insure compliance. All charts are currently compliant for treatment planning. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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 on an interview with the facility director the facility failed to document follow-up on one client who was discharged in the past three months.
Findings Include:
There was one client who was discharged from the program since our last licensing inspection. According to staff interview the facility failed to document follow-up information on this client.
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Plan of Correction
The follow-up log was given to the Clinical Supervisor to complete. The follow-up log will be completed by the clinical supervisor within seven days from discharge hereafter. The Administrative Coordinator will review the log on a weekly basis to insure discharges have been contacted. The Director will do a monthly log audit at the end of each month to insure compliance. |