INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 28, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gage House, LP 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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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
The facility failed to appoint a project director who met the educational and experiential qualifications.
Employee #1 was hired as the project director in August of 2015. During the course of the annual inspection on April 28, 2016, there was no documentation provided to verify the employee's education and experience.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Documentation verifying the employee's education and experience will be placed in their Human Resources file. These documents will include transcripts, diploma, and an updated resume. Facility Director will ensure that appropriate documentation is placed in the HR file. Facility Director will meet with HR to review documentation needs of the facility to ensure that this error does not happen in the future. |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
The facility failed to ensure the exits from the facility were unobstructed during a physical plant inspection on April 28, 2016. At the time of the inspection, a sliding glass door off the screened/glassed in porch was marked as an exit but was blocked by a rack and pictures.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The items blocking the exit were removed while the inspector was in the facility. Reviewed this issue at staff meeting on 5/11/16 so that all staff are aware of the presence of the exit and that access to it must be clear at all times. Director and/or supervisor will monitor all exits in the facility to ensure that clear access is available. |