INITIAL COMMENTS
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This report is a result of an on-site initial licensure inspection conducted on October 30, 2015 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Gaudenzia Erie, Inc., 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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704.5(a) LICENSURE Project/Facility Director
704.5. Qualifications for the positions of project director and facility director.
(a) A drug and alcohol treatment project shall have a project director responsible for the overall management of the project and staff and each drug and alcohol treatment facility shall have a facility director responsible for the overall management of the facility and staff unless the project has but one facility.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) form and other administrative documentation during the initial onsite licensing inspection of October 30, 2015, the project failed to appropriately identify a project director who is directly responsible to the governing body.
The findings included:
During the licensing inspection of October 30, 2015, a review of the SRFSR and the Organizational Structure chart revealed that the individual that actually oversees the project was not identified as the project director. Instead the individual serving as the facility director was listed as the project director.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based on observation and a physical plant inspection, the facility failed to provide locked storage containers/file cabinets for securing client records.
The findings include:
A physical plant inspection was completed on October 30, 2015. At the time of the physical plant inspection, there were no file cabinets in the file room.
This was reviewed with facility staff.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.94(b) LICENSURE Project management services
709.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on a physical plant inspection, the facility failed to display the hours of project operation to the general public.
The findings include:
A physical plant inspection was conducted on October 30, 2015. The facility did not display the hours of project operation.
These findings were reviewed with facility staff.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.94(c) LICENSURE Project management services
709.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based on a physical plant inspection, the facility failed to display a telephone number to the general public for emergency purposes.
The findings include:
A physical plant inspection was conducted on October 30, 2015. A telephone number that is conspicuously displayed to the general public is required at all outpatient treatment programs. The facility did not display an emergency telephone number.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |