INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 13-15, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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. The following deficiencies were identified during this inspection:
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Plan of Correction
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705.2 (3) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(3) Keep exterior exits, stairs and walkways lighted at night.
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Observations
During a licensing inspection and physical plant inspection conducted on January 13-15, 2020, the facility to keep a fire exit stairway light located on the female floor in working order.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During the time of the inspection on January 13 ? 15, 2020. The fire exit light was out leading to the roof of the women's tower. That light was replaced by maintenance staff immediately during the time of the inspection and while the inspector was present on the floor. Facility Maintenance Staff and or Facility Maintenance Director will conduct monthly inspections of all lights in the inpatient program. |
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
During a licensing inspection and physical plant inspection conducted on January 13-15, 2020, the facility failed to provide either individual paper towels or a mechanical dryer in each bathroom. The male bathroom and medical office bathroom did not have paper towels available.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During the time of the inspection on January, 13-15, the Inpatient Men's Bathroom and Medical Office were restocked with paper towels while the inspection was taking place. Daily rounds of the Inpatient Program and Medical Department by the facility custodian worker will ensure that all bathrooms are replenished with paper towels at least twice a day. |
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
During a licensing inspection and physical plant inspection conducted on January 13-15, 2020, the facility failed to provide documentation of a fire drill being completed during sleeping hours at least every 6 months.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Maintenance Director will develop an annual calendar for all schedule fire drills. The calendar will include at least one overnight fire drill to be conducted at least every 6 months. The Facility Maintenance Director will review the calendar quarterly to ensure that the fire drills are being conducted as scheduled. In the event that the fire drill can not happen on the scheduled day it will be conducted on the very next day by the Facility Maintenance Director. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
During a licensing inspection conducted on January 13-15, 2020, the facility failed to provide documentation on an annual performance evaluation for employees # 1 and 2.
Employee # 1 was hired as the Project Director on June 19, 2015 and was still in this position at the time of the inspection. An annual performance review was not provided in the employee personnel records.
Employee # 2 was hired as the Facility Director on January 1, 2010 and was still in this position at the time of the inspection. An annual performance review was not provided in the employee personnel records.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
During the inspection, January 13 ? 15, the facility did provide employees #1 and # 2 copy of annual individual performance evaluation. Inspector stated she did not see and asked that it be emailed to her during the exit meeting of the inspection. Facility director will ensure that annual evaluations are completed an available annually by collecting the annual evaluations and ensuring each evaluation is entered into Project Director and Facility Director personnel file, utilizing the check off list for all evaluations required annually. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
During a licensing inspection conducted on January 13-15, 2020, the project failed to provide documentation of the client being notified of their rights acknowledging that the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion in seven of seven records reviewed.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Effectively 2/28/20, the Intake Supervisor and Inpatient Director, during the client's admission and/or intake, will review the Bill of Rights with the client. Acknowledgement will be indicated by checking the box in MyAvatar that the client has received the Bill of Rights; additionally all clients will receive a copy of the Client Handbook that includes a copy of the Bill of Rights. Acknowledgement for receipt of the handbook will also be checked in MyAvatar and will be documented in an individual progress note. Review of conformance to compliance standards will occur during monthly and quarterly chart audit reviews. Any deficiencies will be reported to the Inpatient Director.
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709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
During a licensing inspection conducted on January 13-15, 2020, the project failed to provide a complete client rights policy and procedure to include reasons for removing sections shall be documented in the record.
These findings were reviewed with project staff during the licensing inspection.
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Plan of Correction
The facility has reviewed the policy to ensure that the client have the right to inspect their own records the project manager, facility director or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. The reason for removing the sections shall be documented in the chart. This policy shall be reviewed annually to ensure that the policy is being follow by all intake staff, intake supervisor and inpatient director. During the time of intake the intake counselor shall review with client their rights and Intake supervisor will review each record to ensure that the client is signing off in avatar. |
709.34 (a) (1) 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:
(1) Physical assault or sexual assault by staff or a client.
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Observations
During a licensing inspection conducted on January 13-15, 2020, the project failed to provide procedures for responding to a physical assault or sexual assault by staff or a client.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
In the event of any unusual incident, and once the immediate safety of all involved is provided for, staff will ensure that all required notifications are made immediately, especially to the program director or supervisor who will coordinate with staff regarding what other notifications will be made. Staff will document the unusual incident using the standard Gaudenzia incident form and/or the PA State unusual incident form as appropriate to the incident. Afterward, management staff will ensure prompt review and identification of the causes directly or indirectly responsible for the unusual incident, implementing a timely and appropriate corrective action plan when indicated. This plan will be monitored on an ongoing basis to ensure that it is carried out and that it proves to be effective in preventing further incidents. If the nature of the incident is such that it must be reported to any external entities, all Confidentiality guidelines will be followed as outlined in the Confidentiality section of this policy manual and in keeping with all State and Federal laws. Physical assault or sexual assault by staff or a client: Individuals involved will be separated. 911 may be summoned as appropriate. As soon as the immediate safety of all involved/nearby is addressed, notification will be made to the Program Director, Division Director, and Regional Director. If a sexual incident involves any individuals connected to Department of Corrections then all PREA protocols will be enacted as delineated in the PREA policy. All incidents will be investigated, and corrective actions determined based on findings.The corrective action will be completed by the Inpatient director within 24 hours of the incident occurrence.
The facility will review and update all policies and have additional training annually. All staff will be required to sign off on the training and provide feedback for the training, to ensure the deficiency does not occur. Inpatient director will be responsible for implementing the corrective action plan. This plan will be done by February 28, 2020.
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709.34 (a) (2) 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:
(2) Selling or use of illicit drugs on the premises.
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Observations
During a licensing inspection conducted on January 13-15, 2020 the project failed to develop and implement procedures in responding to selling or use of illicit drugs on the premises.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
In the event of any unusual incident, and once the immediate safety of all involved is provided for, staff will ensure that all required notifications are made immediately, especially to the program director or supervisor who will coordinate with staff regarding what other notifications will be made. Staff will document the unusual incident using the standard Gaudenzia incident form and/or the PA State unusual incident form as appropriate to the incident. Afterward, management staff will ensure prompt review and identification of the causes directly or indirectly responsible for the unusual incident, implementing a timely and appropriate corrective action plan when indicated. This plan will be monitored on an ongoing basis to ensure that it is carried out and that it proves to be effective in preventing further incidents. If the nature of the incident is such that it must be reported to any external entities, all Confidentiality guidelines will be followed as outlined in the Confidentiality section of this policy manual and in keeping with all State and Federal laws.
Selling or use of illicit drugs on the premises: If any individuals appear to be intoxicated, they will be evaluated and potentially sent to the hospital for monitoring. If circumstances indicate the potential for opiate overdose, the Naloxone policy and protocol will be followed. Any illicit substances will be confiscated. The Program Director will be notified. The situation will be investigated and corrective actions determined based on findings. Corrective action will be completed by Inpatient director within 24 hours. The facility will conduct annual training for all staff and provide feedback on the training. All staff will sign off on the training. Inpatient director will ensure the the corrective action plan is is implemented. Date of corrective action plan will be February 19, 2020. |
709.34 (a) (3) 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:
(3) Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
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Observations
During a licensing inspection conducted on January 13-15, 2020, the project failed to develop and implement procedures in responding to death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
In the event of any unusual incident, and once the immediate safety of all involved is provided for, staff will ensure that all required notifications are made immediately, especially to the program director or supervisor who will coordinate with staff regarding what other notifications will be made. Staff will document the unusual incident using the standard Gaudenzia incident form and/or the PA State unusual incident form as appropriate to the incident. Afterward, management staff will ensure prompt review and identification of the causes directly or indirectly responsible for the unusual incident, implementing a timely and appropriate corrective action plan when indicated. This plan will be monitored on an ongoing basis to ensure that it is carried out and that it proves to be effective in preventing further incidents. If the nature of the incident is such that it must be reported to any external entities, all Confidentiality guidelines will be followed as outlined in the Confidentiality section of this policy manual and in keeping with all State and Federal laws.
Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services: Notification will be made to the Program Director, Division Director, and Regional Director, as well as Executive Staff. All such deaths will be investigated, and corrective actions determined based on findings. Inpatient director will complete correction action within 24 hours.
The facility will have annual trainings for all staff and staff will provide feedback on the training and sign off on the training. Inpatient director will ensure the corrective action plan is complete. This will occur on February 19, 2020. |
709.34 (a) (4) 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:
(4) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
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Observations
During a licensing inspection conducted on January 13-15, 2020, the project failed to develop and implement procedures in responding to significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
In the event of any unusual incident, and once the immediate safety of all involved is provided for, staff will ensure that all required notifications are made immediately, especially to the program director or supervisor who will coordinate with staff regarding what other notifications will be made. Staff will document the unusual incident using the standard Gaudenzia incident form and/or the PA State unusual incident form as appropriate to the incident. Afterward, management staff will ensure prompt review and identification of the causes directly or indirectly responsible for the unusual incident, implementing a timely and appropriate corrective action plan when indicated. This plan will be monitored on an ongoing basis to ensure that it is carried out and that it proves to be effective in preventing further incidents. If the nature of the incident is such that it must be reported to any external entities, all Confidentiality guidelines will be followed as outlined in the Confidentiality section of this policy manual and in keeping with all State and Federal laws
Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day: Once the immediate situation is addressed and everyone's safety is attended to, staff will notify the Program Director, Division Director, and Regional Director as well as Executive Staff. In the event that the facility is inoperable, all clients will be transported to other Gaudenzia residential programs (as applicable). No one will return to the facility until cleared by Fire or Emergency Service personnel. The situation will be investigated and corrective actions determined based on findings. Inpatient director will complete corrective actions within 24 hours of occurrence.
The facility will conduct annual trainings and have staff sign off n the training as well as complete feedback on the training. Inpatient director will be responsible to ensure the corrective action plan is implemented. This will be completed by February 19, 2020. |
709.34 (a) (5) 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:
(5) Theft, burglary, break-in or similar incident at the facility.
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Observations
During a licensing inspection conducted on January 13-15, 2020, the project failed to develop and implement procedures in responding to theft, burglary, break-in or similar incident at the facility.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
In the event of any unusual incident, and once the immediate safety of all involved is provided for, staff will ensure that all required notifications are made immediately, especially to the program director or supervisor who will coordinate with staff regarding what other notifications will be made. Staff will document the unusual incident using the standard Gaudenzia incident form and/or the PA State unusual incident form as appropriate to the incident. Afterward, management staff will ensure prompt review and identification of the causes directly or indirectly responsible for the unusual incident, implementing a timely and appropriate corrective action plan when indicated. This plan will be monitored on an ongoing basis to ensure that it is carried out and that it proves to be effective in preventing further incidents. If the nature of the incident is such that it must be reported to any external entities, all Confidentiality guidelines will be followed as outlined in the Confidentiality section of this policy manual and in keeping with all State and Federal laws.
Theft, burglary, break-in or similar incident at the facility: 911 will be called immediately. Once the immediate situation is addressed and everyone's safety is attended to, staff will notify the Program Director, Division Director, and Regional Director. The situation will be investigated and corrective actions determined based on findings. In the event that a corrective action is needed Inpatient director will complete it within 24 hours of occurence.
The facility wil conduct annual trainings and staff willl sign off on the training which will include feedback on the training. The inpatient director will ensure the corrective action plan is implemented. Corrective actin plan completed by February 19, 2020. |
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
During a licensing inspection conducted on January 13-15, 2020, the project failed to develop and implement procedures in responding to event at the facility requiring the presence of police, fire or ambulance personnel.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
In the event of any unusual incident, and once the immediate safety of all involved is provided for, staff will ensure that all required notifications are made immediately, especially to the program director or supervisor who will coordinate with staff regarding what other notifications will be made. Staff will document the unusual incident using the standard Gaudenzia incident form and/or the PA State unusual incident form as appropriate to the incident. Afterward, management staff will ensure prompt review and identification of the causes directly or indirectly responsible for the unusual incident, implementing a timely and appropriate corrective action plan when indicated. This plan will be monitored on an ongoing basis to ensure that it is carried out and that it proves to be effective in preventing further incidents. If the nature of the incident is such that it must be reported to any external entities, all Confidentiality guidelines will be followed as outlined in the Confidentiality section of this policy manual and in keeping with all State and Federal laws.
Event at the facility requiring the presence of police, fire or ambulance personnel: Once the immediate situation is addressed and everyone's safety is attended to, staff will notify the Program Director, Division Director, and Regional Director. No one will return to the facility until cleared by Fire or Emergency Service personnel. The situation will be investigated and corrective actions determined based on findings. Inpatient director will complete corrective action within 24 hours of the occurrence.
The facility will conduct annual training for all stafff and staff will completed feedback sheets as well as sign off of the training. Inpatient director will ensure the corrosive action plan is implemented Corrective action plan will be completed by February 19, 2020.
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709.34 (a) (7) 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:
(7) Fire or structural damage to the facility.
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Observations
During a licensing inspection conducted on January 13-15, 2020, the project failed to develop and implement procedures in responding to fire or structural damage to the facility.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
In the event of any unusual incident, and once the immediate safety of all involved is provided for, staff will ensure that all required notifications are made immediately, especially to the program director or supervisor who will coordinate with staff regarding what other notifications will be made. Staff will document the unusual incident using the standard Gaudenzia incident form and/or the PA State unusual incident form as appropriate to the incident. Afterward, management staff will ensure prompt review and identification of the causes directly or indirectly responsible for the unusual incident, implementing a timely and appropriate corrective action plan when indicated. This plan will be monitored on an ongoing basis to ensure that it is carried out and that it proves to be effective in preventing further incidents. If the nature of the incident is such that it must be reported to any external entities, all Confidentiality guidelines will be followed as outlined in the Confidentiality section of this policy manual and in keeping with all State and Federal laws.
Fire or structural damage to the facility: 911 will be called immediately. Once the immediate situation is addressed and everyone's safety is attended to, staff will notify the Program Director, Division Director, and Regional Director. No one will return to the facility until cleared by Fire or Emergency Service personnel. The situation will be investigated and corrective actions determined based on findings. The Inpatient director will complete the corrective action within 24 hours.the facility wil conduct annual training for all staff and all staff will provide feedback sheets and sign off of the training. Inpatient director will ensure the corrective action plan has been implemented. Corrective action plan will be omelets by February 19, 2020. |
709.34 (a) (8) 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:
(8) Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
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Observations
During a licensing inspection conducted on January 13-15, 2020, the project failed to develop and implement procedures in responding to an outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
In the event of any unusual incident, and once the immediate safety of all involved is provided for, staff will ensure that all required notifications are made immediately, especially to the program director or supervisor who will coordinate with staff regarding what other notifications will be made. Staff will document the unusual incident using the standard Gaudenzia incident form and/or the PA State unusual incident form as appropriate to the incident. Afterward, management staff will ensure prompt review and identification of the causes directly or indirectly responsible for the unusual incident, implementing a timely and appropriate corrective action plan when indicated. This plan will be monitored on an ongoing basis to ensure that it is carried out and that it proves to be effective in preventing further incidents. If the nature of the incident is such that it must be reported to any external entities, all Confidentiality guidelines will be followed as outlined in the Confidentiality section of this policy manual and in keeping with all State and Federal laws.
Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification: Affected individuals will be referred for medical attention as appropriate. Staff will notify the Program Director, Division Director, and Regional Director and/or Nursing Director as well as Executive Staff. Notification will be made to the CDC as appropriate and all care will be taken to provide for the confidentiality of all individuals. Medical nursing staff will make notification to all appropriate authorities.
The facility will conduct annual training for all staff and provide feedback to the training as well as sign off sheet of the training. The inpatient director will ensure that the corrective action plan is implemented. Targeted date will be February 19, 2020. |
709.51(b)(7) LICENSURE Preliminary Tx. Plan.
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
During a licensing inspection conducted on January 13-15, 2020, the facility failed to provide preliminary treatment and rehabilitation plans according to the project ' s policy and procedure manual. The policy and procedure manual indicated a preliminary treatment and rehabilitation plan would be developed during the intake process. After review of client records, it was determined the preliminary treatment and rehabilitation plan was not developed during intake in six of seven client records.
Client # 2 was admitted on August 19, 2019 and discharged on October 1, 2019. A treatment and rehabilitation plan was not developed until August 28, 2019.
Client # 3 was admitted on October 9, 2019 and discharged on December 9, 2019. A treatment and rehabilitation plan was not developed until October 15, 2019.
Client # 4 was admitted on November 26, 2019 and was still active at the time of the inspection. A treatment and rehabilitation plan was not developed until December 1, 2019.
Client # 5 was admitted on November 13, 2019 and was still active at the time of the inspection. A treatment and rehabilitation plan was not developed until November 19, 2019.
Client # 6 was admitted on November 21, 2019 and was still active at the time of the inspection. A treatment and rehabilitation plan was not developed until December 9, 2019.
Client # 7 was admitted on November 19, 2019 and was still active at the time of the inspection. A treatment and rehabilitation plan was not developed until December 9, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Intake Supervisor and or Inpatient Director will review all intake procedures to ensure that preliminary treatment plans are completed for each new intake during the intake process. The intake counselor during will be responsible to complete the preliminary treatment and present it to intake supervisor for final approval. Client # 2 admitted on 8/19/19 and discharged on 10/1/19 preliminary treatment plan was not completed within the required timeframe on 8/28/19. Client # 3 was admitted on 10/9/19 and discharged on 12/9/19 preliminary treatment plan was not completed in the required timeframe. Client # 4 admitted on 11/26/19 and preliminary treatment plan was developed in a timely manner on 12/12/19. Client # 5 admitted on 11/13/19 and preliminary treatment plan was developed in a timely manner on 11/19/19. Client # 6 was admitted on 11/21/19 and preliminary treatment plan was not developed in a timely manner until 12/9/19. Client # 7 was admitted on 11/19/19 and preliminary treatment plan was not developed in a timely manner until 12/9/19. All missing preliminary treatment plans for clients #'s 3, 6 & 7 have been completed and uploaded into the system. Inpatient director shall review all preliminary treatment plans to ensure that they are completed during the time of intake with the intake supervisor. |