Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, 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 2, an abbreviated on-site inspection, conducted on December 9, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, Gaudenzia Common Ground 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
Based on a review of seven client records, the facility failed to ensure that work done by the client at the project is an integral part of his treatment and rehabilitation plan in all seven client records reviewed.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Clinical Supervisor will review with all Clinicians the regulation requiring that all work performed within the facility be included in the individual treatment plan as a therapeutic tool.
The Clinical Supervisor will monitor ongoing conformance via monthly record reviews and reporting to the Continuous Quality Improvement Department.
Target Resolution date: 2/1/2021
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