INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on May 12, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Fountain Springs 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:
|
Plan of Correction
|
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
|
Observations
Based on a review of six personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that one employee received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #5 was hired as a counselor on February 25, 2020 and was due to have the communicable disease trainings no later than February 25, 2021. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
The Program Director and Clinical Supervisor will assume responsibility for ensuring that all employee's receive the minimum 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe. Both managers will work collaboratively to register and schedule employee #5 (initials EL) for missed training. Certification of training completion will be maintained in the facility staff training file. A monthly training report will be utilized to monitor ongoing staff training completion.
Targeted completion date: 7/30/21. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
|
Observations
Based on a physical plant inspection, the facility failed to ensure that all bathrooms were maintained in a functional, clean and sanitary manner at all times as the first floor bathroom flooring was ripped up at the entrance and could be a tripping hazard.
These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
The Program Director submitted another work order request to repair/replace the 1st Floor dorm bathroom flooring in the maintenance system on 5/27/21.
The request was also emailed to the Regional Physical Plant Manager (RF) who is responsible to schedule and arrange floor repair/replacement.
Target date for completion is 6/30/21.
Ongoing compliance will be monitored/reported via the monthly Continued Quality Improvement meeting.
|
705.29 (2) (iii) LICENSURE Child care.
705.29. Child care.
When a nonresidential facility admits children for services or for custodial care, the following requirements apply:
(2) Interior space. The nonresidential facility shall:
(iii) Maintain protective caps over each electrical outlet.
|
Observations
Based on physical plant inspection, the facility failed to ensure that all electrical outlets maintain a protective cap in the following rooms:
First Floor rooms 3, 5, and 8
Second Floor rooms 1, 2, 3, 5, 7 and laundry room
Third Floor rooms, 1 and 2b
Bunk Room and Downstairs group room.
These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
Protective caps were purchased and placed in 1st floor rooms 3, 5, 8, 2nd floor rooms 1, 2, 3, 5, 7, laundry room, 3rd floor rooms 2b, bunk room, and group room as required by House Managing staff by 5/27/21.
The Administrative Coordinator/Acting House Manager Supervisor reviewed with all staff and clients the importance of maintaining outlet caps to preserve safety.
To monitor ongoing compliance, House Managing staff will conduct daily facility outlet inspections and submit documented findings to on duty supervisor for review and additional correction if needed.
Targeted resolution date: 6/30/21 |