INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 8, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of 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:
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Plan of Correction
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705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a review of fire extinguisher inspections, the facility failed to ensure fire extinguishers were inspected and approved annually by the local fire department or fire extinguisher company. The facility ' s fire extinguishers were last inspected in June of 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Manager will schedule a fire inspection with the local department by the end of July 2025. Approval will be marked on the extinguisher and logged into internal tracking to ensure that the fire system undergoes an annual inspection. Project Director will monitor to ensure compliance with fire inspections. |
709.30 LICENSURE Client Rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
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Observations
Based on applicable client records reviewed, the facility failed to ensure there was appropriate documentation of written acknowledgment by the client that the client had been made aware of their rights in seven of seven records.
Client #1 was admitted to on September 25, 2024 and discharged on October 29, 2024. There was no written acknowledgment by the client they had been made aware of their rights.
Client #2 was admitted to on December 30, 2024 and discharged on March 11, 2025 There was no written acknowledgment by the client they had been made aware of their rights.
Client #3 was admitted to on December 10, 2024 and discharged on April 10, 2025. There was no written acknowledgment by the client they had been made aware of their rights.
Client #4 was admitted to on November 14, 2024 and discharged on June 10, 2025. There was no written acknowledgment by the client they had been made aware of their rights.
Client #5 was admitted to on October 23, 2024 and discharged on April 29, 2025. There was no written acknowledgment by the client they had been made aware of their rights.
Client #6 was admitted to on August 6, 2024 and was still active at the time of the inspection. There was no written acknowledgment by the client they had been made aware of their rights.
Client #7 was admitted to on April 17, 2025 and discharged on June 26, 2025. There was no written acknowledgment by the client they had been made aware of their rights.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will add an electronic client acknowledgement signature to the client handbook by 8/1/2025 for the client to confirm that their rights have been reviewed with them upon completion of their client orientation with their therapist. Project Director will monitor for compliance with corrective action plan.
Chart review audits performed monthly will monitor compliance ongoing. These are reviewed by Clinical Director as well as Program Supervisor. |