INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 25 -26, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Ellen O'Brien Gaiser Addiction Center 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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705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on observation and a physical plant inspection, the facility failed to provide an unobstructed exit from the front entrance.
The findings include:
A physical plant inspection was conducted on July 26, 2011. A key deadbolt is located on the front entrance to the facility. Therefore, this exit is not unobstructed and operable at all times.
The project director confirmed the key deadbolt on the front entrance of the facility on July 26, 2011 at 8:45 AM.
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Plan of Correction
The Executive Director, Linda Franiewski along with the Gaiser Center Maintenance Personnel, Mel Risinger, reviewed the front exit and concluded a thumb lock will correct the problem of the exit being obstructed. Mel Risinger, installed a thumb lock on the front exit on 8/18/2011. The thumb lock creates an unobstructed exit. The exit fully complies with Fire Safety Regulations. |
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 on a review of client records, the facility failed to document follow-up attempts in two of the three client records.
The findings include:
On July 26, 2011, eight client records were reviewed. Three of the eight client records were required to include documentation of follow-up attempts. The facility failed to document follow up attempts in two of the three client records, specifically client records #1 and #3.
The facility follow-up policy, states the client will be contacted via telephone one week and five weeks following discharge, and documentation will be noted in the client record.
Client record # 1 failed to include documentation of a follow up attempt. Client # 1 was admitted on 2-9-11 and discharged on 6-8-11. The follow up attempt was due by 6-15-11, and 7-13-11. There was no documentation of attempts to follow up on the client.
Client record # 3 failed to include documentation of a follow up attempt. Client # 3 was admitted on 2-14-11 and discharged on 5-17-11. The follow up attempt was due by 5-24-11 and 6-21-11. There was no documentation of attempts to follow up on the client.
This was discussed with and confirmed by the clinical director on 7-26-11 at 3:00 PM. The clinical director confirmed that the follow up attempts for these clients were not documented at the time of the licensing inspection.
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Plan of Correction
Effective 8/15/2011, upon review of current data collected in the 5 week follow-ups, the Clinical Director, Dr. Jeff Geibel and the Executive Director, Linda Franiewski, determined the 5 week follow-up attempt is not a reliable statistic. The 5 week follow-up will be discontinued due to unreliable data. The revised follow-up policy will be limited to a one week follow-up which will be in full compliance with State regulations. |