INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 27 - April 28, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia DRC Inc was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
The program is a 24 hour residential facility.
The staff schedules and CPR certification cards for March and April 2016 were reviewed on April 28, 2016. The facility was unable to provide documentation to verify that a sufficient number of staff persons trained in CPR were onsite during all hours on April 1 and April 15, 2016.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Human Resource Generalist and Human Resource Director will review all staff trainings for CPR and distinguish which staff members are in need of training. CPR training will be provided to those individuals that have not had training and schedule them for training. The training will be held monthly starting in May and once a month for the next six months. The HR Generalist will review the staff training files bi-annually for staff that are still in need of training, anyone that has missed training or for newly employed staff. The training will then be held every other month.
The next year, the HR Generalist and HR Director will review the annual training plans for all staff and schedule staff every other month to ensure that all staff are trained and or retrained for CPR. All CPR Certification Cards (Copies) will be kept in each employees training file. These steps will ensure that all staff remains current with the training and that there will be at least one staff member on shift certified. In addition, the HR Generalist will monitor the schedule for individuals working any shift and that there are certified staff members working.
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705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
A review of the fire drill logs was conducted on April 27-28, 2016. Noted in the fire drill log for January 30, 2016 was an entry detailing a fire resulting from inadequate maintenance of a clothes dryer vent.
A physical inspection was conducted on April 27, 2016. Observed in one out of the two facility dumpsters the lid on the container was damaged as to allow for the possible intrusion of rodents or other pests; also the side door was broken through.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Facility Maintenance Director contacted our vendor - Waste Management for a replacement dumpster. New dumpster delivered to facility. Dumpster will be monitored by shift supervisor during perimeter checks during each shift. |
705.10 (b) (6) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(6) Maintain all smoke detectors and fire alarms so that each person with a hearing impairment will be alerted in the event of a fire, if one or more residents or staff persons are not able to hear the smoke detector or fire alarm system.
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Observations
A physical plant inspection was conducted on April 27, 2016 at approximately 9:00 AM. During the inspection it was observed that the facility failed to provide a fire alarm so that each person with a hearing impairment will be alerted in the event of a fire on the 7th floor.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Maintenance Director contacted our vender to install a new fire alarm (Strobe Light)to the 7th floor women's unit - room 708. Work was completed on 5/18/16. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
The fire drill record was reviewed on April 28, 2016 for the period covering October 2015 through March 2016. During that timeframe, the facility did not document any fire drills conducted during sleeping hours. A further review of the fire drill records to determine when the last fire drill conducted during sleeping hours had been conducted revealed that there were no documented sleeping hour drills since 2014.
An interview with the facility director on April 28, 2016 confirmed the findings.
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Plan of Correction
The Operations Director will create a schedule for all monthly fire drills. All drills will be monitored by Operations Director to ensure that there is an overnight drill within the six month time frame. All drills will be logged in the facility fire drill log book. The Inpatient Director will also monitor the fire drill schedule to ensure there is a drill every month as well as a drill overnight within the six month timeframe. |
709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
The policy and procedure manual was reviewed on April 27, 2016 for the facility policy regarding confidentiality. The facilities policy and procedure failed to address crimes on program premises or against program personnel, reports of suspected child abuse and neglect, and agreements with Qualified Service Organizations.
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Plan of Correction
The Facility Director and Accreditation & Administrative Manager will update the policy and procedure manual to include items that can be released without consent from the client. These items will include crime on premises or personnel, reports of child abuse or neglect, and agreements with qualified service organizations. This will be reviewed on an annual basis. |
709.28 (c) 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.
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Observations
Twenty client records were reviewed on April 27- 28, 2016 for informed and voluntary consent to release informaion forms. The facility failed to document informed and voluntary consent to release information forms in client records # 14 and 19.
Client #14 was admitted on January 8, 2016 and discharged on February 17, 2016. The facility failed to document the specific information disclosed on the informed and voluntary consent to release information form for a government agency in client record, #14.
Client #19 was admitted on February 18, 2016 and discharged on March 21, 2016. The facility failed to document the specific information disclosed on the informed and voluntary consent to release infromation form for family members in client record, #19.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Any new consents to release information will be reviewed by the clinical supervisor to ensure that the forms are complete containing all required information and in compliance with federal and state confidentiality regulations. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Twenty client records were reviewed on April 27 and April 28, 2016 for informed and voluntary consent forms. The facility failed to document if the client was offered a copy of the informed and voluntary consent forms.
Client #4 - The facility failed to document whether or not the client was offered a copy of the of the consent to release information form for a government agency dated January 27, 2016.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor and or Inpatient Director shall review all voluntary consent forms to ensure that the client has been offered a copy of the release of information form. If not offered to the client, the client will be contacted and offered copy of the consent form. Client will indicate that he/she received a copy or denied wanting a copy by checking off the box to indicate which choice he/she decides. |
709.34 (a) (6) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
The unusual incident report, policy and procedure manual was reviewed on April 27, 2016. The facilities failed to file a written usual incident report within 3 business days. The presence of the fire department was documented in the facility's Fire Drill Log on January 30, 2016, February 18, 2016 and February 22, 2016. No incident reports were sent to the Department.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All unusual incidents will be monitored by Clinical Supervisor and Inpatient Director. Clinical Supervisor and or Inpatient Director will be responsible to complete all unusual incident reports. All unusual reports will be forwarded to DDAP within three days by the Clinical Supervisor or Inpatient Director. Clinical Supervisor or Inpatient Director will fax the unusual report to DDAP via fax and will staple the confirmation form to the actual incident report and keep on file. |