INITIAL COMMENTS
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This report is a result of an on-site follow-up inspection to the initial on-site licensure inspection conducted on June 9, 2010 by staff from the Division of Drug and Alcohol Program Licensure.
The follow-up inspection was conducted on November 17, 2010 by staff from the Division of Drug and Alcohol Program Licensure.
Based on the findings of the onsite follow-up inspection, Gaudenzia Washington 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 and a plan of correction is due on January 9, 2011.
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Plan of Correction
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704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
This deficiency can not be re-evaluated until the next licensing inspection.
Please resubmit the original plan of correction date for the date of completion.
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Plan of Correction
Program director and administrative coordinator will review trainings attended by staff and monthly evaluations to ensure that trainings completed and filed in personelcharts and filed by months end. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
This deficiency can not be re-evaluated until the next licensing inspection.
Please resubmit the original plan of correction date for the date of completion.
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Plan of Correction
Program director has been given required training hours standards for all positions at Washington House. As part of monthly reporting,Program Director will list trainings for each staff quarterly andreport out in monthlyfacility narrative. Administrative coordinator will ensure regisrtations for training and filing of training certificate in personnel charts monthly. |
705.10 (b) (6) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(6) Maintain all smoke detectors and fire alarms so that each person with a hearing impairment will be alerted in the event of a fire, if one or more residents or staff persons are not able to hear the smoke detector or fire alarm system.
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Observations
Based on a physical plant inspection and a conversation with the Facility Director, the facility failed to maintain all smoke detectors and fire alarms so that each person with a hearing impairment will be alerted in the event of a fire.
The findings include:
A physical plant inspection was conducted on November 17, 2010.
The facility failed to provide a bedroom equipped with a strobe light or shaker bed to alert each person with a hearing impairment in event of a fire.
A conversation with the Facility Director confirmed that the facility is not equipped with a strobe light or a shaker bed.
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Plan of Correction
Program Director will contact the Philadelphia Detection System company to install a strobe light and any other equipment needed for ADA bedroom;to ensure that a hearing impaired client will be alerted in the event of a fire. |
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 a review of client records and a review of the policy and procedures manual, the facility failed to document follow-up information.
The findings include:
The facility's policy states:
20. Follow Up: Within seven (7) days of the date of a referral appointment made for a client leaving treatment, the referral shall be contacted by the Counselor to determine if the client kept the initial appointment and if the referral was appropriate. In the case of a client ending treatment without a referral appointment (ASA, Therapeutic Discharge, Completion who refuses further treatment), the client shall be contacted directly by the counselor or supervisor's designee to determine the client ' s well-being and to maintain the opportunity for re-admission should circumstances warrant it as necessary and appropriate. This will occur within the 7 days post discharge. Information shall be kept in the follow up log binder.
On November 17, 2010 two client records were reviewed for documentation of follow-up information.
The facility did not document follow-up information within 7 days from the date of discharge, as per facility policy, in client record # 6.
Client # 6 was admitted to the program on 7/29/10 and discharged on 9/1/10.
Client # 6 was referred to an outpatient facility, the appointment date was 9/7/10.
At the time of review on 11/17/10 follow-up information was not documented.
This is a repeat deficiency.
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Plan of Correction
The Program Director will review the Client Follow Up log monthly, to make sure that the program supervisor documents information for all discharged clients whose names are listed on the the monthly Follow Up log. |