INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 9, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of 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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709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on applicable client records reviewed, the facility failed to provide documentation of the project notifying the client, in writing, of a decision to involuntarily terminate the client's treatment in one of one records.
Client #6 was admitted on October 22, 2024 and discharged on December 3, 2024. There was no documentation in the client record notifying the client in writing of termination from the project.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the July 10, 2024 annual licensing inspection.
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Plan of Correction
The Clinical Director will add IT paperwork to the EMR for electronic signatures, eliminating the need for hard copy paper documentation that can be lost or forgotten to upload into the system. Clinical Director and/or Sr. Program Counselors will monitor usage through quarterly chart audits and report findings to project director. |
709.51(a)(4) LICENSURE Involuntary discharge/termination criteria
709.51. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(4) Involuntary discharge/termination criteria.
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Observations
Based on a review of client records, the facility failed to notify the emergency contact of a client's decision to leave against facility advice in one of three applicable records.
The facility's inpatient non-hospital residential policy and procedure manual states the client ' s emergency contact will be notified within 12 hours of the client ' s decision to leave against facility advice, providing there is consent given in writing for the facility to contact the emergency contact.
Client #3 was admitted to the residential level of care on February 28, 2025 and discharged on May 2, 2025. The release to contact the emergency contact was signed on February 28, 2025.
This finding was reviewed with the facility staff during the licensing process.
This is a repeat citation from the July 10, 2024 annual licensing inspection.
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Plan of Correction
AMA letter that is given to client at discharge or mailed to last known address will be updated to reflect the date and time of contact made to emergency contact by counselor. This will be signed by counselor, client, and clinical director, and uploaded into chart after all signatures obtained. This will be monitored by Clinical Director and Project Director during quarterly chart audits. |
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 client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every thirty days in three of six applicable records.
Client #1 was admitted on November 20, 2024 and was discharged on January 9, 2025. A treatment and rehabilitation plan was developed on November 27, 2024. A treatment and rehabilitation plan update was due no later than December 27, 2024, but was not completed until December 29, 2024.
Client #3 was admitted on February 28, 2025 and was discharged on May 2, 2025. A treatment and rehabilitation plan updated was completed on March 28, 2025. A treatment and rehabilitation plan update was due no later than April 28, 2025, but was not completed until April 30, 2025.
Client #5 was admitted on November 11, 2024 and was discharged on January 21, 2025. A treatment and rehabilitation plan updated was completed on November 18, 2024. A treatment and rehabilitation plan update was due no later than December 18, 2024, but was not completed until December 29, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director and Project Director will review repeat findings in the clinical staff meeting. THe Clinical Director will review findings of occurrences where charts treatment plans are updated past 30 days in quarterly chart audits. Those counselors who repeat this offense will be subject to progressive disciplinary action from HR. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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 applicable client records reviewed, the facility failed to provide follow-up contact in accordance with the facility policy and procedure manual in three of six records.
The policy and procedure manual indicates follow-up contact must be made within seven days after discharge.
Client #2 was admitted on January 7, 2025 and was discharged on February 12, 2025. The follow-up contact was due to be completed no later than February 19, 2025 but, this was not completed at the time of the inspection.
Client #3 was admitted on February 28, 2025 and was discharged on May 2, 2025The follow-up contact was due to be completed no later than May 9, 2025 but, this was not completed at the time of the inspection.
Client #5 was admitted on November 11, 2024 and was discharged on January 21, 2025. The follow-up contact was due to be completed no later than January 28, 2025 but, this was not completed at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the July 10, 2024 annual licensing inspection.
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Plan of Correction
Clinical Director and Project Director will review findings with the staff. Our intake department will add a column "due for follow-up" to census to remind counselors to make the follow-up. Clinical Director and Project Director will monitor during quarterly chart audits and report findings to staff. Staff who consistently fail to document will be subject to progressive disciplinary action by HR and/or the Project Director. |