INITIAL COMMENTS
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This report is a result of a supervisory review of the written report of the findings of an on-site licensing inspection that was conducted on May 28, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the supervisory review of findings from the on-site 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 supervisory review and a plan of correction is due.
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Plan of Correction
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709.53(a) LICENSURE Complete Client Record
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:
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Observations
Based on a review of administrative documentation, the facility failed to provide a complete client record which includes information relative to the client's involvement with the project for 9 drug and alcohol clients.
The findings include:
On May 28, 2015, the facility failed to provide clinical documents for 9 clients, specifically the clients residing in bedrooms 3, 4, and 5 as they were not initially identified as drug and alcohol clients during the licensing inspection. In addition, facility staff stated that drug and alcohol regulations were not used to document the client records in bedrooms 3, 4, and 5 as those client records follow the Department of Corrections regulations.
The Facility Director confirmed the finding on the submitted and approved plan of correction which documented; "At the time of the site inspection, the clients residing in bedrooms, 3, 4, and 5, were not included on the census sheet. For future inspections, the Program Director will ensure that a complete census sheet showing all clients in residence shall be given to the licensing specialist..."
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Plan of Correction
Program Director has ensured that all current clients are reflected on census sheet.
Administrative coordinator will reflect all current clients on weekly census reports.
All of washington house's client's are D&A clients and the facility will comply with D&A regulations regarding those clients including allowing full and free access to the facility and the client records for inspections.
The Division Director and the Program Director will have oversite to ensure compliance with all D&A regulations. |
709.15(b) LICENSURE Subchapter B.Licensing Procedures.Right to en
709.15. Right to enter and inspect.
(b) The authorized Department representative shall have full and free access to the records of the facility and its clients.
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Observations
Based on a review of administrative documentation, the facility failed to provide the authorized Department representative full and free access to the records of the facility and its clients.
The findings include:
On May 28, 2015, the facility failed to provide the authorized Department representative full and free access to the records of the facility and its clients. The facility failed to provide clinical documents for 9 clients, specifically the clients residing in bedrooms 3, 4, and 5 as they were not initially identified as drug and alcohol clients during the licensing inspection..
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director has ensured that all clients are reflected on the census sheet.
Program Director will ensure that the census sheet provided for licensing inspections reflects all clients residing at the facility.
Weekly census reports generated by the administrative coordinator will be reviewed by both the program director and division director to ensure that the census sheet is complete and meets regulatory standards. |