INITIAL COMMENTS
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This report is a result of an on-site, licensure renewal inspection conducted on October 24, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Erie, Inc. was found to be not 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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705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection conducted on October 24, 2017 the facility failed to keep the facility in good repair at all times.
The exit way from the basement to the parking lot had a sewer clean out in the floor, which left a 6 " wide by 4" deep hole that created a tripping hazard.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Operations Manager will contact two local contractors to acquire estimates to fill the 6" wide by 4" deep hole by 11/15/2017.
Operations Manager will review estimates with Division Director and choose the contractor of choice to come complete the work of leveling the ground by filling the hole. The hole will be filled on the first available date given by the contractor.
Operations manager will block off the area with caution tape by 11/10/17 and remove once repairs are completed. |
705.10 (a) (1) (v) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
Based on a physical plant inspection conducted on October 24, 2017, the facility failed to ensure all exits from the facility were lit at all times.
The stairwell from the basement to the first floor was not properly illuminated and only residual light from the lighting fixture in the basement was illuminating the bottom steps, leaving the top 3 steps and landing area unlit.
Additionally, The doorway from the basement to the parking lot was not illuminated.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Operations Manager replaced and added lighting to the steps leading from the basement to the 1st floor and put a new light from the doorway out of the basement to the parking lot. This was completed 11/6/2017.
Operations Manager will complete monthly facility runs starting November 2017 to ensure all lights are in working order. |
705.11 (2) (iii) LICENSURE Child care.
705.11. Child care.
(2) Interior space. The residential facility shall:
(iii) Maintain protective caps over each electrical outlet.
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Observations
Based on a physical plant inspection conducted on October 24, 2017, the facility failed to cover the 220 volt outlet in the basement laundry area.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Operations Manager contacted a local electrician and had the 220 volt outlets removed from the area on 10/26/2017. |
709.30 (1) 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.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
The facility failed to document written acknowledgement by the client that they were notified of all of their rights in seven of seven client records reviewed on October 24, 2017.
There was no documentation that the client was informed that the project, facility or clinical director would document the reason for removal from the client's record of any material deemed detrimental to the client in client records # 1, 2, 3, 4, 5, 6 and 7.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Division Director will review and adjust agency policy as needed to ensure all required client rights are listed in rights that are reviewed with clients upon admission. Division Director will complete this review by 11/14/2017.
Division Director will review agency policy/client rights with the Program Director by 11/17/2017.
Program Director will review updated policy/client rights with all staff by 11/21/2017.
Staff will begin using updated policy/client rights with all clients starting 11/22/2017.
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709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Seven client records were reviewed on October 24, 2017. The facility failed to update the treatment plan every 30 days in two of six applicable records.
Client #6 was admitted on August 21, 2017 and discharged on October 21, 2017. The comprehensive treatment plan was documented on August 30, 2017; a treatment plan update was due by September 30, 2017 but was not documented until October 18, 2017.
Client #7 was admitted on April 11, 2017 and discharged on July 10, 2017. A treatment plan update was documented on May 19, 2017; a treatment plan update was due by June 19, 2017 but was not documented until June 21, 2017.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Program Director will meet with all clinical staff by 11/23/2017 and review treatment plan and treatment plan update requirements and time frames.
Program Director will complete monthly chart audits starting in November 2017 to ensure that all treatment plans are completed in a timely manner and in accordance with all regulations.
Program Director will report findings from the monthly chart audits in the agency monthly quality improvement meeting starting 12/20/2017. Any identified issues will be resolved through solution focused discussions in this meeting. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Seven client records were reviewed on October 24, 2017. The facility failed to provide counseling according to the treatment plan in seven of seven client records reviewed.
Clients # 1-7 did not receive weekly individual counseling sessions as indicated on the treatment plans.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Program Director will meet with all clinical staff and discuss the requirement of making sure services that are documented on the treatment plan, such as individual sessions, need to be followed in the actual services provided. Program Director will meet with clinical staff by 11/23/2017.
Program Director will complete monthly chart audits to ensure that services identified on the treatment plans are being provided as stated. Monthly chart audits will begin looking at this area of concern in November 2017.
Program Director will report findings from monthly chart audits in the agencies monthly quality improvement meeting starting on 12/20/2017. |