INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 5 - 8, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Erie Inc. Edinboro Satellite Office 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 September 5, 2008.
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Plan of Correction
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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based upon a review of the facility's fire drill record on August 8, 2008, the facility failed to maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
The findings were:
The exit route used was not documented in any of the fire drills conducted.
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Plan of Correction
A fire drill was conducted on 8/24/2008 and the exit route used was documented. The Program Supervisor and Division Director will ensure that monthly fire drills document what exit route is used. This will be reviewed monthly during the Safety Committee meeting and the Quality Improvement meeting. |
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 upon a review of the facility's fire drill record on August 8, 2008, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings were:
The exit route used was not documented in any of the fire drills conducted; therefore, it was not possible to determine if the facility had prepared and practiced using alternate exits.
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Plan of Correction
A fire drill was conducted on 8/24/2008 and the exit route used was documented. The Program Supervisor and Division Director will ensure that monthly fire drills document what exit route is used. This will be reviewed monthly during the Safety Committee meeting and the Quality Improvement meeting. |
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 upon a review of the facility's 2006 - 2007 annual report and an interview with the facility director, both occurring on August 8, 2008, the facility failed to make the annual report for Gaudenzia Erie Inc. available to the general public.
The findings were:
The facility failed to advertise where and when the annual report would be available for public viewing.
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Plan of Correction
The Regional Director will ensure that Gaudenzia Erie is represented in the annual Gaudenzia Inc. report. He will continue to monitor this annually. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based upon a review of three client records on August 8, 2008, the facility failed to document a complete medical history in one of three client records reviewed.
The findings were:
Client record #1 lacked the client's family medical history.
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Plan of Correction
Division Director met with clinical staff to ensure that the proper clinical documents were being used that included a family medical history. This seems to have been a training issue for when the satellite first opened and since has been corrected. The Program Supervisor will audit clinical files monthly to ensure that all clinical documents are completed. The outcome of these audits will be reviewed with the Division Director during monthly Quality Improvement meetings. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based upon a review of three client records on August 8, 2008, two records required that the client histories be completed based upon the time frame within the facility's policy and procedures. The facility failed to provide a complete drug and alcohol history in one of two client records reviewed.
The findings were:
Client record #2 did not include the client's drug of choice, length and patterns of use and the client's perception in the client's drug and alcohol use history.
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Plan of Correction
Division Director met with clinical staff to ensure that the proper clinical documents were being used that included a complete drug and alcohol history. This seems to have been a training issue for when the satellite first opened and since has been corrected. The Program Supervisor will audit clinical files monthly to ensure that all clinical documents are completed. The outcome of these audits will be reviewed with the Division Director during monthly Quality Improvement meetings. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based upon a review of three client records on August 8, 2008, two records required that the client histories be completed based upon the facility's policy and procedures. The facility failed to provide a complete personal history in two of two records reviewed.
The findings were:
Client records #1 & 2 did not document if the client had any military history.
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Plan of Correction
Division Director met with clinical staff to ensure that the proper clinical documents were being used that included a complete personal history. This seems to have been a training issue for when the satellite first opened and since has been corrected. The Program Supervisor will audit clinical files monthly to ensure that all clinical documents are completed with personal history that includes military history. The outcome of these audits will be reviewed with the Division Director during monthly Quality Improvement meetings. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based upon a review of three client records on August 8, 2008, the facility failed to provide a preliminary treatment plan as per facility policy and procedures in one of three records reviewed.
The findings were:
Client record #1 did not include a preliminary treatment plan.
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Plan of Correction
Division Director met with clinical staff to ensure that the clinical files contained a preliminary treatment plan. The Program Supervisor will audit clinical files monthly to ensure that all clinical files contain a preliminary treatment plan. The outcome of these audits will be reviewed with the Division Director during monthly Quality Improvement meetings. |
709.93(a)(2) 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:
(2) Medication records.
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Observations
Based upon a review of three client records on August 8, 2008, one of three records required that the facility document client medications including the dosage and frequency. The facility failed to document client medications to include the dosage and/or frequency in one of one records reviewed.
The findings were:
Client record #3 did not include the frequency for the medications listed in the record.
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Plan of Correction
Division Director met with clinical staff to ensure that the clinical files contained documentation of client medications which includes dosage and frequency. The Program Supervisor will audit clinical files monthly to ensure that all clinical files document the client medications that include dosage and frequency. The outcome of these audits will be reviewed with the Division Director during monthly Quality Improvement meetings. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based upon a review of three client records on August 8, 2008, two records required that a follow up be conducted. The facility failed to conduct a follow up within seven days of a referral appointment as per the facility policy and procedures in one of two records reviewed.
The findings were:
Client record #3 indicated that the client was discharged and referred on 7/8/08 and had not had a follow up until 7/19/08.
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Plan of Correction
Division Director met with Administrative Coordinator about following time frames for client follow-up. Program Supervisor will ensure that policy time frames are being followed and continue to be followed. |