INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 9-10, 2024, 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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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
Based on a review of administrative information, the facility failed to collect feedback on completed trainings in four of four applicable personnel records.Facility policy and procedures state that feedback forms are to be completed after each training. The training year beginning July 1, 2023, through June 30, 2024 was reviewed and feedback was not collected for any training.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Effective on 8/1/2024, the Human Resources Manager will oversee the completed internal feedback collection forms. When the Human Resources Manager becomes aware that staff have registered for training, the HR Manager will issue the feedback form. HR Manager will monitor collection of the feedback forms and will not issue training credit until HR Manager can verify the collection of the internal feedback form. |
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 a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in one of one applicable client record.Client #4 was admitted on January 29, 2024, and discharged on February 19, 2024. This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Effective 8/1/2024, the Clinical Director will hold a staff meeting with the clinical staff to review this regulation for Involuntary Termination. Future internal chart audits performed by Clinical Director and/or Sr Counselor will note if this is not happening and review findings with the appropriate staff. |
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 one applicable record.The facility's policy and procedure manual states the client ' s emergency contact will be notified of a client ' s decision to leave against facility advice, providing there is consent given in writing to contact the emergency contact.Client #3 was admitted on October 17, 2023, and was discharged on November 18, 2023. There was a consent for the emergency contact in client #3 ' s record.This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Effective on 8/1/2024, the Clinical Director will hold a staff meeting reviewing this regulation with clinical staff about against facility advice discharges. Future internal chart audits performed by the clinical director and/or the sr clinician will note areas where this is not occurring and review findings with the appropriate staff. |
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, the facility failed to document follow-up information in two of four discharged records.The facility's policy and procedure manual states follow up contact is to be completed for all discharges within 7 days.There was no follow up information documented in client records #3 and #4.Client #3 was admitted on October 17, 2023, and was discharged on November 18, 2023. Client #4 was admitted on January 29, 2024, and was discharged on February 19, 2024. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Effective 8/1/2024, the Clinical Director will meet and review these findings with staff about the 7-day follow-up contacts. Future internal chart audits performed by the Clinical Director will note areas where this is not occurring and will review the findings with the appropriate staff. |