INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 25 & 26, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gaudenzia - Coal Township 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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705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of the June 2022 through February 2023 fire drill log, the facility failed to conduct a fire drill during sleeping hours at least every 6 months.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Fire Drills will be completed during sleeping hours at least every 6 months. This will be coordinated by the Program Director and carried out by the overnight shift staff.
The Program Director reviewed this with all staff during a staff meeting on 4/20/23, and an overnight fire drill was successfully completed by 3rd shift on 5/11/23. This was documented on the fire drill log per policy and drills will continue to be documented via the fire drill grid going forward
The Program Director will review the grid before the end of each month to ensure that all drills have been completed according to regulations. |
709.62(c)(3)(ii) LICENSURE D & A History
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on the review of client records, the facility failed to document a complete drug and alcohol history per the facility ' s policy and procedures manual requiring the histories to be completed within 72 hours of admission in two out of six applicable records.
Client #2 was admitted on April 21, 2023 and was still active at the time of the inspection. There was no documentation that a drug and alcohol history was completed.
Client #5 was admitted on August 6, 2022 and discharged on August 12, 2022. The drug and alcohol history was due no later than August 9, 2023; however, it was completed on August 11, 2023
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Histories and Psychosocial Evaluation will be completed according to policy.
In instances at the 3.7 Withdrawal Management program where a client is feeling too ill to participate in this process, this will be documented via an independent note and/or medical note in the EHR. This requirement was discussed with all staff on 4/26/23 in a documented clinical meeting.
During regular monthly audits, a sample of charts will be audited by the Clinical Supervisor to ensure that this is completed. Any issues identified will be discussed with the clinician and corrected within 48 hours.
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709.62(c)(3)(iii) LICENSURE Personal history
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on the review of client records, the facility failed to document a personal history per the facility ' s policy and procedures manual requiring the histories to be completed within 72 hours of admission in two out of six applicable records.
Client #2 was admitted on April 21, 2023 and was still active at the time of the inspection. There was no documentation that a personal history was completed.
Client #5 was admitted on August 6, 2022 and discharged on August 12, 2022. The personal history was due no later than August 9, 2023; however, it was completed on August 11, 2023
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Histories and Psychosocial Evaluation will be completed according to policy.
In instances at the 3.7 Withdrawal Management program where a client is feeling too ill to participate in this process, this will be documented via an independent note and/or medical note in the EHR. This requirement was discussed with all staff on 4/26/23 in a documented clinical meeting.
During regular monthly audits, a sample of charts will be audited by the Clinical Supervisor to ensure that this is completed. Any issues identified will be discussed with the clinician and corrected within 48 hours.
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709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to document a psychosocial evaluation per the facility ' s policy and procedures manual requiring it to be completed within 72 hours of admission in two out of six applicable records.
Client #2 was admitted on April 21, 2023 and was still active at the time of the inspection. There was no documentation that a psychosocial evaluation was completed.
Client #5 was admitted on August 6, 2022 and discharged on August 12, 2022. The psychosocial evaluation was due no later than August 9, 2023; however, it was completed on August 11, 2023
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Histories and Psychosocial Evaluation will be completed according to policy.
In instances at the 3.7 Withdrawal Management program where a client is feeling too ill to participate in this process, this will be documented via an independent note and/or medical note in the EHR. This requirement was discussed with all staff on 4/26/23 in a documented clinical meeting.
During regular monthly audits, a sample of charts will be audited by the Clinical Supervisor to ensure that this is completed. Any issues identified will be discussed with the clinician and corrected within 48 hours.
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