INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 22-24, 2019, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Erie Inc./Community 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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705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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 on a review of the facility records conducted during the on-site inspection, the facility failed to ensure that it documented all of the required information on its fire drill records.
The facility has four exits, but the specific exits used were not documented for the fire drills conducted on July 13, 2019, July 30, 2019, and September 25, 2019.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Program Director and Safety Committee designee will ensure proper and detailed completion of the fire drill record on a monthly basis by completing a monthly fire drill log record review monthly starting December 1st, 2019.
Program Director reviewed proper documentation of fire drills with all staff individually on 10/24/2019 and with all staff during the monthly staff meeting on 11/05/2019 |
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
Based on a review of facility records conducted during the on-site inspection, the facility failed to ensure that it updated treatment plans at least once every 30 days in 3 of 7 inpatient records reviewed.
Client #1 was admitted for treatment on May 28, 2019, and discharged on July 15, 2019. The client's individualized treatment plan was dated June 6, 2019, but the client's treatment plan was never updated.
Client #3 was admitted for treatment on July 30, 2019, and was an active client at the time of the on-site inspection. The client's individualized treatment plan was dated August 8, 2019, but the client's treatment plan was not updated until October 12, 2019.
Client #5 was admitted for treatment on February 5, 2019, and was discharged on May 1, 2019. The client's individualized treatment plan was dated February 19, 2019, but the the client's treatment plan was not updated until March 26, 2019.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
Program Director will review required timelines for updated treatment with all clinical staff by 12/10/2019.
Facility counselors will begin to use a tracking system to monitor due dates for treatment plan updates by 12/10/2019.
Program Director will ensure treatment plan updates are completed within the required timeframes through the CQI process starting in November 2019. |