INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 7 and 8, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia at Sunbury 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 July 7, 2010.
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Plan of Correction
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705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a review of the physical plant, it was determined that the facility failed to have hot water under pressure.
The findings were:
A physical plant tour was conducted on June 8, 2010 at 10:10 am. The bathroom on the second floor in the "attorney's office" building did not have hot water. The inspector attempted to turn on the hot water, however no water came out of the faucet.
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Plan of Correction
The hot water knob on the second floor bathroom sink was turned on by the Program Director as of 6-9-10.
A sign has been posted in the bathroom stating that the hot water is not to be turned off for any reason. Prior to the start of Monday morning group the assigned Counselor will do a physical plant check to ensure that the water is indeed turned on. |
709.93(a)(9) LICENSURE Client records
709.93. 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records and the facility's policies and procedures, the facility failed to document an aftercare plan to include a contact person and the criteria for readmission in two of two client records.
The findings include:
Ten client records were reviewed on May 7, 2010. An aftercare plan was required in two client record; the facility failed to include the criteria and person to contact for re-admission in both of the client records. The facility's policy states:
An Aftercare Plan should be completed by the Primary Counselor and the client.
This plan includes the following information:
1. Future goals and objectives with time frames.
2. Services to be provided and proposed frequency of contact during Aftercare.
3. Projected date of Aftercare Termination.
4. Criteria and person to contact for re-admission
In client record # 8, the client was admitted on 12/10/09 and was discharged on 4/22/10. The aftercare plan completed on 4/8/2010 and did not include criteria and person for re-admission.
In client record # 10, the client was admitted on 11/20/09 and was discharged on 5/17/10. The aftercare plan completed on 5/10/2010 and did not include criteria and person for re-admission.
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Plan of Correction
On June 11, 2010 a mini in-service on aftercare plans and re-admission criteria was provided to the staff by the Program Director. A monthly utilization review will be completed on discharge files by Administrative Coordinator and results reviewed by the Program Director. In addition all aftercare plans will be reviewed and signed off on by the Clinical Supervisor. |