Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on October 29, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, Gaudenzia Inc. Vantage 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:
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Plan of Correction
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Observations
Based on a review of seven client records, the facility failed to keep all releases for all seven records for the funding source and probation office within the limits of 255.5. These releases all included the release of treatment plans, progress notes, medication records and assessments.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Administrative Assistant was made aware of the issue concerning going outside of PA Code 255.5 on releases obtained during the intake process as of 10/30/20 and a subsequent supervisory session will occur with the Administrative Assistant by her supervisor, the Administrative Coordinator. This session will occur by 11/9/20.
An all staff training will be conducted on 11/5/20 regarding a refresher on the requirements under PA Code 255.5 in the event another staff person is assigned the duties of intake or need to complete a release.
To prevent this from reoccurring, the Clinical Supervisor and Administrative Coordinator will review compliance regarding confidentiality during their monthly qualitative chart audit.
Person Responsible: Clinical Supervisor and Administrative Coordinator.
Person responsible for the Monitoring: Program Director. |