INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 13, 2023, 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.- Integrity 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 inspection:
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Plan of Correction
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to provide a written individual training plan for each employee, appropriate to that employee's skill level that documented it was developed annually with input from both the employee and the supervisor in one out of six personnel records reviewed.
Employee #1 was hired on September 9, 2019 as a project director and was still in that position as of the date of the inspection. The individual training plan had no documentation that the plan was developed with input from both the employee and supervisor and the date completed.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The development of all individual training plans will be documented in the staff file via a supervision note and/or through the signature of the staff member and supervisor on a printed plan. Documentation of this will be presented in a timely manner to DDAP personnel in preparation for annual licensing visits. All Gaudenzia managers have been reminded of this requirement via email memo from the Director of Regulatory Standards as of 4/18/23. Regarding the Project Director's ITP, the ITP for calendar year 2024 will be developed and signed by the Project Director and Chief Executive Officer by Feb 29th, 2024.
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709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of the facility ' s unusual incident reports, the facility failed to inform the Department of an event at the facility requiring the presence of fire personnel.
The facility documented an unusual incident on December 27, 2022, which involved the presence of the fire department at the facility for a false fire alarm, however the facility did not submit a written unusual incident report to the Department.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Staff have been educated by the Program Director as of 4/18/23 regarding the requirement to complete a DDAP Unusual Incident Report for all unusual incidents involving any event at the facility requiring the presence of police, fire, or ambulance personnel (even in the instances of a false alarm). The Program Director will review all incident reports completed at the facility and will submit all required reports to DDAP within 3 business days.
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