INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 11 -15, 2008 by staff from the Division of Drug and Alcohol 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 and a plan of correction is due on September 15, 2008.
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Plan of Correction
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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the fire drill log on 8-11-08, the facility failed to document fire drills for the period of time between November 2007 to February 2008.
Finding:
Documentation of fire drills was missing for November 2007, December 2007, January 2007 and February 2007.
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Plan of Correction
During the inspector's visit, it was discovered that a counselor that left the Gaiser Center in February 2008 failed to provide documentation of fire drills for the period November 2007 to February 2008. On August 14, 2008, the Executive Director met with the counselor and all employees at 325 New Castle Rd., Butler, PA and the Fire Drill Policies and procedures were reviewed. The Director expressed the importance of complying 28 PA Code. The finding was corrected as fire drills have been done since March 2008 and all relevent staff have received fire safety training on August 14, 2008. |
709.23(a) LICENSURE Project Director
709.23. Project director.
(a) The project director shall prepare and annually update a written manual delineating project policies and procedures.
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Observations
Based on the administrative manual review on 8-11-08 and 8-12-08, the facility failed to present a complete and consistent manual.
Finding:
The recently revised manual did not include consistency between policies and procedures, lacked details in numerous areas, and referred several times to the Assistant Director, but this position does not exist in this organization.
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Plan of Correction
The Project Director and the Administrative Assistant, along with input from the State Licensing Specialist,reviewed the administrative manual and noted any inconsistent policies and/or language. The Administrative Assistant under the direction of both the Clinical and Execitive Director is correcting any errors. The revised administrative manual will accurately reflect all current Gaiser Policies and procedures and will be in full compliance with State and other funding sources' contracts. The manual will be completed by September 30, 2008. |
709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
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Observations
Based on the review of the facility's client handbook on 8-12-08, the facility failed to notify clients of their civil rights.
Finding:
There was no documentation to demonstrate that the clients had been informed of their rights.
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Plan of Correction
Effective 8/14/08 The Executive Director added to the client handbook a complete listing of clients rights including instructions on "Inspecting Your Personal Records". All clients recieve a client handbook when admitted. |