INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 20, 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. People With Hope/Short-Term Program 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 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on a physical plant inspection on June 20, 2023, the facility failed to ensure that garbage was stored in covered containers that prevent the penetration of insects and rodents as a trash receptacle in the sallyport of the building was uncovered.
This is a repeat citation from the June 14, 2022 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facilities Manager created a signage and schedule to ensure that the trash containers are closed to prevent animals/ rodents from penetrating containers on 7/30/2023.
Front desk will monitor the trash receptacles by viewing the cameras and will close the lids when they are open.
The Facility Manager will review at least weekly.
The Manager on Duty for the building will monitor the containers daily.
The QA Manager reviews the physical plant on a quarterly basis, to include the condition of the dumpster. Any issues noted will be brought to the attention of the FM. |
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.
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Observations
Based on a physical plant inspection on June 20, 2022, the facility failed to maintain each bathroom in a functional and clean manner as the bathroom for room 206 was undergoing renovations and missing toilet paper and a mirror. The shared bathroom for rooms 204 and 202 appeared to be undergoing renovations as well, and was missing a mirror, an operable soap dispenser, and toilet paper.
This is a repeat citation from the June 14, 2022 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All repairs have been completed (6/22/2023).
Going forward, the Program Director will submit maintenance requests through the new electronic system for all necessary repairs.
Maintenance will ensure that all repairs are done in a timely manner.
The QA Manager reviews the physical plant on a quarterly basis, to include the condition of the bathrooms. Any issues noted will be brought to the attention of the Facility Manager for immediate remediation.
Assistant Director Maintenance is responsible for the facilities repairs. |
705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a physical plant inspection on June 20, 2023, the facility failed to keep frozen food at or below 0 degrees Fahrenheit, as the walk-in freezer in the kitchen was 12 degrees.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Kitchen Manager will ensure that Freezer temperatures are monitored on a daily basis and documented in a log. Any issues noted will be brought to the attention of the maintenance department to immediately repair.
On 6/29/23, the freezer was repaired.
Additionally, Gaudenzia is hiring new Facility Manager for the 1306 Spring Garden Street building to oversee all physical plant areas, including the kitchen.
The QA Manager reviews the physical plant on a quarterly basis, to include Freezer temperatures and logs. Any issues noted will be brought to the attention of the Kitchen Manager for immediate remediation.
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705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection on June 20, 2023, the facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company as the fire extinguisher in the basement pantry indicated that the most recent inspection and approval occurred in October 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Assistant Director of Maintenace will ensure that all fire extinguishers are updated annually by the local extinguisher company and/or fire department. Kitchen Manager will check the fire extinguisher in the pantry monthly and document that he has inspected the extinguisher.
The QA department will perform a quarterly review of Fire Drill documentation. Any issues noted will be brought to the attention of the Program Director for immediate action.
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705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill logs from July 2022 through June 2023, the facility failed to conduct unannounced fire drills at least once a month as there were no fire drills conducted in July, August, or October 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Recovery Support Professionals will conduct unannounced monthly fire drills on each shift. The Recovery Support Professional Supervisor will monitor and ensure that each unannounced drill is correctly documented in the logbook monthly.
The Program Director will ensure that unannounced fire drills are conducted and documented on each shift.
The Program Director will review Fire Drill Logs/Reports. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of fire drill logs from July 2022 through June 2023, the facility failed to ensure that fire drill logs included the exit route used for each fire drill conducted. The exit route was missing on the logs from November 2022, April 2023, May 2023, and June 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This will be addressed with all staff during an in-service training during staff meeting no later than 8/18/23. Staff will be provided with an example of a completed fire drill log, and they will be required to complete a log to ensure proper understanding and documentation of a fire drill log.
The Program Director will review Fire Drill Logs/Reports prior to the end of each month to ensure that this has been completed.
The QA department will perform a quarterly review of Fire Drill documentation. Any issues noted will be brought to the attention of the Program Director for immediate action.
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709.63(a)(2) LICENSURE D & A support plan
709.63. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(2) Drug and alcohol support plan.
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Observations
Based on a review of client records and the facility's policies and procedures, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include a drug and alcohol support plan within 24 hours of admission, in four of seven records reviewed.
Client # 1 was admitted on July 22, 2022 and was discharged on July 24, 2023. The record did not contain a drug and alcohol support plan.
Client # 2 was admitted on September 21, 2022 and was discharged on September 26, 2022. The record did not contain a drug and alcohol support plan.
Client # 3 was admitted on January 20, 2023 and was discharged on January 25, 2023. The drug and alcohol support plan was not completed until January 23, 2023.
Client # 5 was admitted on May 24, 2023 and was discharged on May 27, 2023. The record did not contain a drug and alcohol support plan.
These finding were discussed with facility staff during the licensing process.
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Plan of Correction
The Program Director will review the requirements regarding Treatment Planning with all staff during staff in-service no later than 8/18/23. This training will include review of the standard workflow, and reference the specific form in our EHR.
In addition, the Program Director and Clinical Supervisor will monitor this area during monthly file audits and address discrepancies during staff supervisions.
The QA department will monitor this area during quarterly CQI file audits and will report findings to the Program Director.
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709.63(a)(7) LICENSURE Discharge summary
709.63. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(7) Discharge summary.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include a discharge summary, in three of seven records reviewed.
Client # 1 was admitted on July 22, 2022 and was discharged on July 24, 2023. The record did not contain a discharge summary.
Client # 3 was admitted on January 20, 2023 and was discharged on January 25, 2023. The record did not contain a discharge summary.
Client # 5 was admitted on May 24, 2023 and was discharged on May 27, 2023. The record did not contain a discharge summary.
This is a repeat citation from the June 14, 2022 annual licensing inspection.
These finding were discussed with facility staff during the licensing process.
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Plan of Correction
The Program Director will review the requirements regarding completion of Discharge Summaries with all staff during staff in-service no later than 8/18/23. This training will include review of the standard workflow, and reference the specific form in our EHR.
In addition, the Program Director and Clinical Supervisor will monitor this area during monthly file audits and address discrepancies during staff supervisions.
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709.63(a)(8) LICENSURE Follow-up Information
709.63. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(8) Follow-up information.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include follow-up information, in three of four applicable records reviewed.
Client # 1 was admitted on July 22, 2022 and was discharged on July 24, 2023. The record did not contain follow-up information.
Client # 4 was admitted on March 7, 2023 and was discharged on March 14, 2023. The record did not contain follow-up information.
Client # 5 was admitted on May 24, 2023 and was discharged on May 27, 2023. The record did not contain follow-up information.
This is a repeat citation from the June 14, 2022 annual licensing inspection.
These finding were discussed with facility staff during the licensing process.
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Plan of Correction
This will be completed by the Primary Clinician or designee for all discharge individuals within the required timeframes.
The Program Director/ Clinical Supervisor will review the requirements regarding Follow Up with all staff.
Clinical Supervisor will audit client charts twice a month. During clinical meetings weekly Clinical Supervisor will remind clinicians to ensure they complete their follow-up calls and document the call. |
709.14(b)(3) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(3) Change in location of the facility.
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Observations
Based on an administrative review of documents and a physical plant inspection, the facility failed to notify the Department within 90 days, of a change in the location of the facility. The facility is licensed to operate on the second and eighth floors of the building; however, it is operating on the second and third floors of the building.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Regulatory Standards and Executive Director will submit the required documentation to DDAP no later than 8/31/23.
In the future, DDAP will be made aware of any such changes in location within the 90 day timeframe.
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