INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 27, 2008 through February 28, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Focus House 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 March 28, 2008.
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Plan of Correction
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704.1-704.2(a) LICENSURE Staffing Compliance Plan
CHAPTER 704. STAFFING REQUIREMENTS FOR DRUG AND ALCOHOL TREATMENT ACTIVITIES
704.1. Scope.
This chapter applies to staff persons employed by drug and alcohol treatment facilities which are licensed or approved under Chapters 157, 709 and 711 (relating to drug and alcohol services; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility) with the exception of staff persons employed in intake, evaluation and referral facilities as delineated in Chapter 709, Subchapter D (relating to standards for intake, evaluation and referral activities) and Chapter 711, Subchapter C (relating to standards for intake, evaluation and referral activities). Staff persons shall possess the qualifications set forth in this chapter and shall also participate in training as required in this chapter.
704.2. Compliance plan.
(a) The project's governing body shall approve a written compliance plan to insure that the staff persons affected by this chapter meet the appropriate educational and experiential qualifications and receive training as stipulated in this chapter.
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Observations
Based on a review of administrative records, the facility failed to document the project's governing body approval of the written compliance plan ensuring that the staff persons affected by this chapter met the appropriate educational and experiential qualifications and receive training as stipulated in Chapter 704.
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Plan of Correction
The Governing Body will Review Chapter 704 and rewrote the written documentation to reflect adhereance to Chapter 704. |
705.9 (4) (i) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(4) Provide written procedures for staff and residents to follow in case of an emergency which shall include provisions for:
(i) The evacuation and transfer of residents and staff to a safe location.
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Observations
Based on a review of the emergency and disaster plan, the facility failed to document a plan for the evacuation and transfer of residents and staff to a safe location for this facility.
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Plan of Correction
A plan for evacuation to tranfer resident's and staff fo a safe location has been implemented completed by Focus House Staff.
A Evacuation Procedures for Disaster Plan |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based on a review of the physical plant on February 28, 2008, the facility failed to ensure that the second means of egress, which led to the rooftop of the facility, was unobstructed. The door was stuck and required significant effort to open.
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Plan of Correction
The House Managers will check fire exit doors daily to ensure fire exit doors are operable. The door to ensure a second means of egress has been fixed to allow movement of staff and clients. |
705.10 (d) (8) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(8) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the fire drill record, the facility failed to set off the fire alarm system or smoke detector during fire drills on 8/11/07, 9/23/07, 9/15/07, 10/7/07, 10/27/07, 11/25/07, 11/7/07, 12/12/07, 1/9/08, 1/26/08, 2/9/08 and 2/18/08.
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Plan of Correction
Focus House implemented a policy that at each Fire Drill to use our Fire Alarm System located at Front of Building. Also new Fire Drill forms have been implemented. Before Fire Drills are done Focus House will call fire department to inform them a fire drill is about to be performed. House Managers will setoff fire alarm for each fire drill. House Managers will review Fire Drill records to ensure documentation is complete. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on a review of administrative records, the facility failed to document an annual report for the 2006 - 2007 fiscal year.
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Plan of Correction
The Annual Report was made available on 3/24/08 by Director of Development.
The Director of Operations will review to ensure that the Annual Report is completed timely every year.
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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 document the notification of termination in one of one record reviewed, #4.
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Plan of Correction
Program Supervisor will review the policy and re-orient all staff in the proper procedure in recording notice of terminations. Program Supervisor will conduct monthly audits to assure that the noticifications are place as needed. |
709.71(b)(4) LICENSURE Consent to Residency
709.71. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to residency.
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Observations
Based on a review of client records, the facility failed to remove references to treatment and rehabilitation services from the consent to residency form in three of three client records reviewed, #1, 2 and 3. This facility is licensed as a transitional living facility and does not provide treatment services.
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Plan of Correction
Director of Operations has changed all consent forms with the words treatment & rehabilitation. Consent to Treatment has been changed to Consent to Residency. This change has been in effect since 2-29-08. |
709.73(a)(1) LICENSURE Target population
709.73. Client management services.
(1) Defined target population.
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Observations
Based on a review of the policy and procedure manual, the facility failed to document the defined target population for this program.
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Plan of Correction
The define target population for this program has been insitituted in the policy and proceedure by the Staff Development Dicector. |
709.73(a)(2) LICENSURE Written Procedures/Mngt Res Serv
709.73. Client management services.
(2) Written procedures for the management of residential services for clients.
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Observations
Based on a review of the policy and procedure manual, the facility failed to include specific procedures for the management of the residential services for clients within a transitional living facility. The procedures presented during the inspection were for inpatient non-hospital rehabilitation treatment services and referenced treatment services. The procedures stated that a treatment plan was to be completed within 3-5 days; the client was to receive at least two individual treatment sessions within the first seven days of treatment; the client was to have revised and updated treatment plans; and the discharge criteria included that the client should demonstrate adequate achievement of treatment goals.
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Plan of Correction
The Policy & Procedure Manual has has been revised to reflect the services of the transitional living facility and all references to treatment have been removed by Staff Development Director. Furthermore, the revised manual for Focus House has been reviewed and approved by Board of Directors. |