INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 20, 2022, 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(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of five staff records on April 21, 2022, the facility failed to ensure that one staff had the required number of training hours for the past training year.
Staff #2 was hired as the facility director on October 21, 2019. Staff #2 was required to have 12 hours of training in the past training year, however only had 8.75 hours documented at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
704.11(d)(2) Annual Training Requirements
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually.
Staff #2 was hired as the facility director on October 21, 2019. Staff#2 was required to have 12 hours of training in the past training year, however only had 8. 75 hours documented at the time of the inspection.
Program Director has completed several trainings already for this year, and upon completion of a 16-hour training scheduled for May 25th, 2022, she will be well above the 12 hour requirement, which needs to be met by October 21, 2022.
In the future, the Deputy Regional Director will meet on at least a quarterly basis with the Program Director in Supervision to review training requirements and progress toward completion. This will be documented in a supervision note.
The Quality Assurance department will conduct at least quarterly reviews which include review of all open Plans of Correction to ensure full implementation.
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705.5 (a) (1) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(a) In each residential facility bedroom, each resident shall have the following:
(1) A bed with solid foundation and fire retardant mattress in good repair.
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Observations
Based on a physical plant inspection on April 21, 2022, the facility failed to ensure all bedrooms had beds with solid foundations and fire retardant mattresses in good repair.
One bed in bedroom # 3 was missing a mattress.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
705.5. Sleeping accommodations:
(a) In each residential facility bedroom, each resident shall have the following:
(1) A bed with solid foundation and fire retardant mattress in good repair.
One bed in bedroom # 3 was missing a mattress. These findings were discussed with facility staff during the licensing process.
This bed frame was inadvertently placed in a bedroom in anticipation of our intention to increase our capacity. There was no mattress because it was not being used by any client, as there were 16 beds with mattresses to accommodate our maximum capacity of 16. The bed will be moved to another area of the building until such time as an increase in capacity is granted and a mattress is available to be placed on the bedframe.
The Quality Assurance department will conduct at least quarterly reviews which include review of all open Plans of Correction to ensure full implementation.
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705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection on April 21, 2022, the facility failed to provide either paper towels or a mechanical dryer in client bathrooms.
Both common bathrooms on the second floor and bedrooms #1, #9, and #10 did not have individual paper towels or a mechanical dryer in each bathroom.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
705.6 (2) Bathrooms.
The residential facility shall: (2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
Both common bathrooms on the second floor and bedrooms #1, #9, and #10 did not have individual paper towels or a mechanical dryer in each bathroom.
Paper towels will be provided in all bathrooms. Daily house runs will be completed and documented in a log to ensure the overall maintenance of the facility to include adequate supplies in every bathroom. If supplies in a specific bathroom are low, they will be re-stocked immediately. If supplies in the building are running low, more will be ordered in a timely manner to ensure that the program is not left without supplies such as paper towels.
The Program Director will review and initial the log at least weekly to ensure compliance.
The Quality Assurance department will conduct at least quarterly reviews which include review of all open Plans of Correction to ensure full implementation.
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705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection on April 21, 2022, the facility failed to ensure the hot water temperature did not exceed 120F.
The hot water temperature in the downstairs client bathroom and the upstairs common bathroom read 138F.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
705.6 (3) Bathrooms.
The Residential facility shall: (3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
The hot water temperature in the downstairs client bathroom and the upstairs common bathroom read 138F.
The Plumber has already adjusted the heater to ensure proper maximum temperature below 120F. Temperature checks will be completed at least weekly and documented in a log to ensure proper temperatures not exceeding 120F. Any deviation from this maximum temperature will be brought to the attention of the Program Director, and a plumber will be called to make adjustments.
The Program Director will review and initial the log at least monthly to ensure compliance.
The Quality Assurance department will conduct at least quarterly reviews which include review of all open Plans of Correction to ensure full implementation.
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705.6 (6) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(6) Provide toilet paper at each toilet at all times.
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Observations
Based on a physical plant inspection on April 21, 2022, the facility failed to provide toilet paper at each toilet at all times.
The client bathroom on the first floor did not have any toilet paper in the bathroom.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
705.6. Bathrooms.
The residential facility shall: 6) Provide toilet paper at each toilet at all times.
The client bathroom on the first floor did not have any toilet paper in the bathroom.
Toilet paper will be provided in all bathrooms. Daily house runs will be completed and documented in a log to ensure the overall maintenance of the facility to include adequate supplies in every bathroom. If supplies in a specific bathroom are low, they will be re-stocked immediately. If supplies in the building are running low, more will be ordered in a timely manner to ensure that the program is not left without supplies such as toilet paper.
The Program Director will review and initial the log at least weekly to ensure compliance.
The Quality Assurance department will conduct at least quarterly reviews which include review of all open Plans of Correction to ensure full implementation.
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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 on April 21, 2022, the facility failed to not permit heaters that were not permanently mounted or installed.
The facility had portable heater in the project director's office.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
705.8 (2) Heating and cooling.
The residential facility: (2) May not permit in the facility beaten that arc not permanently mounted or installed.
The facility had portable heater in the project director's office.
This heater was removed on 4/21/22, the day of the inspection.
Daily house runs will be completed and documented in a log to ensure the overall maintenance of the facility to include the absence of any portable heaters. If any such heaters are found, they will be immediately removed and brought to the attention of the Program Director and the Deputy Regional Director.
The Program Director will review and initial the log at least weekly to ensure compliance. The Deputy Regional Director will review this regulation in documented supervision with the Program Director.
The Quality Assurance department will conduct at least quarterly reviews which include review of all open Plans of Correction to ensure full implementation.
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705.10 (c) (2) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(2) Maintain at least one portable fire extinguisher with a minimum of an ABC rating in each kitchen.
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Observations
Based on a physical plant inspection on April 21, 2022, the facility failed to maintain at least on portable fire extinguisher with a minimum of ABC rating in the kitchen.
The facility only had a fire extinguisher with a rating of K in the kitchen area.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
705.10 (c) (2) Fire safety.
(c) Fire extinguisher. The residential facility shall: (2) Maintain at least one portable fire extinguisher with a minimum of an ABC rating in each kitchen.
The facility only had a fire extinguisher with a rating of K in the kitchen area.
ABC-rated Fire Extinguishers will be installed in the kitchen area in addition to the K-rated Fire Extinguishers. This will be completed by 5/31/22.
Daily house runs will be completed and documented in a log to ensure the overall maintenance of the facility to include the presence of an ABC-rated Fire Extinguisher in the kitchen area. Any deviation from this regulation will brought to the immediate attention of the Program Director to be corrected.
The Program Director will review and initial the log at least weekly to ensure compliance. The Deputy Regional Director will review this regulation in documented supervision with the Program Director.
The Quality Assurance department will conduct at least quarterly reviews which include review of all open Plans of Correction to ensure full implementation.
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