INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 20, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Inc. Winner Co-Occurring Women and Children Program 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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705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, the facility failed to ensure all facility heaters were permanently mounted or installed.
At the time of the inspection, there was a portable space heater located in the nurse's office.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
- The space heater was immediately removed from the nurse's office on the day of the audit.
- A facility-wide sweep was completed to ensure no other portable heaters or non-compliant items were in use.
Prevention:
- A Physical Plant Safety Checklist has been implemented and will be reviewed monthly.
- Staff will be re-educated on prohibited items in the facility during team meetings and orientation.
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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients in one of one applicable records reviewed.
The facility policy and procedure manual stated a client's emergency contact would be contacted within twelve hours of client leaving treatment against staff advice.
Client # 7 was admitted on December 20, 2024 and was discharged against staff advice (ASA) on December 24, 2024. There was no documentation in the record indicating the emergency contact was notified of the client's status of treatment.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
- Staff have been retrained on emergency contact procedures during unplanned discharges.
- A reminder was posted in the staff office outlining notification timelines.
Prevention:
- A discharge protocol checklist was implemented, requiring supervisor sign-off to ensure notification procedures are followed.
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709.28 (c) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to ensure informed and voluntary consent to release information forms included the name, agency, or organization to whom disclosure is made in one of seven records reviewed.
Client #3 was admitted on April 2, 2025 and was active at the time of inspection. The record included a consent to release information form, signed by the client on April 30, 2025, but the form was missing the full name to whom disclosure was to be made.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
- A new ROI was completed to include the full name.
- All staff will complete a mandatory Release of Information training conducted by the CQI department on 6/30/2025
Prevention/training:
- All ROI forms must now include the full name of the individual or full organization. Initials are not permitted.
- Blank ROIs are strictly prohibited.
- All ROIs will be routed to the Clinical Supervisor and/or Program Director for review and approval prior to being filed.
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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 maintain a complete client record, which is to include the documentation of follow-up information, in two of four applicable records reviewed.
Client # 5 was admitted on October 7, 2024 and was discharged on December 13, 2024. There was no follow-up information documented in the record as of the date of the inspection.
Client # 7 was admitted on December 20, 2024 and was discharged on December 24, 2024. There was no follow-up information documented in the record as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
- Staff were retrained on documentation requirements for discharge and follow-up.
Prevention:
- All discharge summaries and follow-up contact notes will now be routed to the Clinical Supervisor and/or Program Director for approval prior to finalization.
- A tracking system is now in place to ensure follow-up contacts are documented within the required timeframe.
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