INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 20-23, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Ellen O'Brien Gaiser Addiction Center 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 August 21, 2009.
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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:
Fire drill logs were reviewed on July 22, 2009. The facility did not document any alternate exit routes used during fire drills. The front door was the exit route used during every fire drill.
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Plan of Correction
Effective immediately following the State Inspection of July 22,2009 the Gaiser Center began conducting periodic fire drills utilizing alternate exits; front and rear. The Executive Director will take responsibility for ensuring the fire drills are conducted appropriately. |
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
Based on a review of administrative policies and procedures and an interview with the executive director, the facility failed to provide documentation of a written agreement with a licensed hospital or physician, for 24 hour emergency psychiatric coverage.
The findings include:
The administrative policies and procedures were reviewed on July 20-23, 2009. The facility was unable to provide a written agreement with a licensed hospital or physician for 24 hour emergency psychiatric coverage, as required.
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Plan of Correction
The Executive Director revised Gaiser Center's written agreement with The Butler Memorial was revised on July 23, 2009 to incude 24 hour emergency psychiatric coverage, as required.
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709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, in one of two client records.
The findings include:
Seven client records were reviewed on July 20-23, 2009. One record was required to include documentation of the notification to the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, in client record # 7. In client record #7, the client was involuntarily terminated from the project on May 7, 2009. There was no documentation of written notification to the client.
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Plan of Correction
Effective July 23, 2009 the Clinical Director and all counselors reviewed the Gaiser Center's policy regarding documentation of the notification to the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. All counselors will be certain to make sure this policy is followed going forward. Utilizing periodic chart audits, the Clinical Director will ensure that involuntary termination notifications occur when terminations occur |
709.33(b) LICENSURE Notification of Termination
709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on the review of client records, the facility failed to give the client an opportunity to request reconsideration of a decision to terminate treatment.
The findings include:
Seven client records were reviewed on July 20-23, 2009. The project was required to give the client an opportunity to request reconsideration of a decision terminating treatment in one client record. The project did not document that the client was given an opportunity to request reconsideration in client record # 7.
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Plan of Correction
Effective July 23, 2009 the Clinical Director and all counselors reviewed the Gaiser Center's policy providing the client an opportunity to request reconsideration of a decision terminating treatment in one client record. All counselors will be certain to make sure this policy is followed and documented going forward. Utilizing periodic chart audits, the Clinical Director will ensure that opportunities to request reconsideration of the discharge decision occurs when the terminations occur |