INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 5, 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. Broad Street 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(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
Based on a review of staff schedules and First Aid certifications provided by the facility, the facility failed to ensure that at least one person trained in First Aid was onsite during the project's hours of operations. The following shifts did not have staff trained in First Aid:3/27/22 - 11:00 p.m. - 7:00 a.m.4/5/22 - 11:00 p.m. - 7:00 a.m. 4/9/22 - 11:00 p.m. - 7:00 a.m.4/10/22 - 11:00 p.m. - 7:00 a.m.4/14/22 - 11:00 p.m. - 7:00 a.m.4/23/22 - 11:00 p.m. - 7:00 a.m.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director has ensured that CPR/First Aid training is scheduled to be completed for the staff member who was missing the First Aid portion on 06/07/2022.
In the meantime, the Program Director has amended the schedule to ensure that staff with CPR/First Aid training are available on all shifts.
The Program Director will also review training requirements on a monthly basis to ensure that all staff training are up to date, and to ensure that any staff who are nearing the deadline will be scheduled to complete the training prior to the due date. |
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 May 5, 2022, the facility failed to ensure that each bathroom has paper towels or a mechanical dryer and an operable soap dispenser in each bathroom. Two bathrooms on the second floor did not have paper towels or a mechanical dryer and the women ' s bathroom did not have an operable soap dispenser. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The paper towel dispenser were filled on 5/5/2022 in all client bathrooms.
The maintenance department was contacted on 5/9/2022 and soap dispensers were installed and filled on 5/9/2022.
The status of paper towel and soap dispensers will be monitored daily through daily facility runs. These are documented on a run sheet which lists these are specific areas to check. Any low supplies will be immediately replenished.
Additionally, the Program Director will conduct weekly reviews of run sheets to ensure ongoing compliance.
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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 the physical plant inspection on May 5, 2022, the facility failed to ensure that the hot water temperature did not exceed 120 degrees Fahrenheit.When tested, the water in the third-floor client bathroom was 129 degrees Fahrenheit.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the October 28, 2020 and June 8, 2021 annual licensing inspections.
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Plan of Correction
The maintenance department made adjustments to the water temperature on 5/24/22, but temperature readings since then indicate that the the temperature requires further adjustment to ensure that it remains below 120F. The Deputy Regional Director will coordinate with the Director of Maintenance to ensure that this is a priority. This will be completed no later than 6/17/22.
A new, more accurate, digital thermometer was purchased for the facility so that accurate weekly readings by facility staff can be taken and documented on the run sheet. All readings will now be taken using this thermometer during weekly safety runs. Any reading above 118F will be brought to the immediate attention of the Program Director to be addressed with the maintenance department. The Program Director will monitor these readings on a monthly basis to ensure that they are being completed.
The maintenance staff will also check the hot water temperature on a weekly basis to ensure that the temperature of the hot water does not exceed 120F. This will allow maintenance to make immediate adjustments if the reading does become too close to 120F.
In addition, the water temperature will be monitored by the CQI Department during quarterly CQI site inspections and findings will be reported to the Program Director.
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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 May 5, 2022, the facility failed to ensure that facility heaters were permanently mounted or installed. Portable heaters were found in the Director ' s office, client bedroom #1, and multiple counselor offices.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The space heater was removed from the facility on 5/5/2022.
Facility staff will monitor for the presence of portable heaters during weekly safety checks, which are documented on a log. Any portable heater will be brought to the immediate attention of the Program Director for removal.
The Program Director will monitor this log on at least a monthly basis.
In addition, the presence of portable heaters will be monitored by the CQI Department during quarterly CQI site inspections and any findings will be reported to the Program Director for immediate removal.
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705.10 (a) (1) (iv) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(iv) Clearly indicate exits by the use of signs.
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Observations
Based on a physical plant inspection on May 5, 2022, the facility failed to clearly indicate exits by the use of signs. A stairway in the basement labeled with an "Exit" sign led to a locked door. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director contacted the maintenance department on 5/6/2022 to request removal of the sign.
On 5/15/2022 the exit sign was removed.
Weekly safety inspections will be conducted, including checking for clear access to all modes of egress. Any issues in this area will be noted on the log and brought to the immediate attention of the Program Director to be addressed. The Program Director will monitor the log on a monthly basis to ensure compliance.
In addition, clear egress will be monitored by the CQI Department during quarterly CQI site inspections and any findings will be reported to the Program Director for immediate action.
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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 May 5, 2022, the facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The tag on the fire extinguisher located in the Nurse ' s station, indicated that the most recent inspection and approval occurred in November 2020. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director alerted the maintenance department on 5/9/2022 who has scheduled the fire extinguisher inspection agency to come to the facility on or before 6/9/2022 to inspect or replace this fire extinguisher as appropriate.
Fire Extinguishers are inspected at least monthly by facility staff which is documented on the fire Extinguisher tags and in the safety report. The Program Director will the safety report each month to ensure compliance.
In addition, fire extinguishers are monitored by the CQI Department during quarterly CQI site inspections and any findings will be reported to the Program Director for immediate action. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of five personnel files, the facility failed to ensure that each staff was instructed in the use of the fire extinguishers upon employment in one record reviewed.Employee #5 was hired as a House Manager on August 16, 2021 and was due to be trained in the use of fire extinguishers by August 23, 2021; however, fire safety training was not documented as complete until September 9, 2021.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will ensure that all new hires receive the adequate fire safety training within the first 7 days of employment. This will be done by reviewing all new hire requirements with each new employee at the end of their first 5 days of employment. Any staff who have not yet had the training at that point will received it immediately.
This will be documented in the staff file for each employee. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of seven client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients in one record reviewed.Client #1 was admitted on February 17, 2022 and discharged Against Medical Advise (AMA) on March 9, 2022. The facility failed to follow their policy related to AMA discharges of calling the Emergency Contact within twelve hours. These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
This will be completed for all ASA discharges.
Program Director will review the policy again with all staff in an in-service training no later than 6/17/22.
The Program Director will review all client files at time of discharge to ensure that this has been completed. Any chart missing this notification will be brought to the attention of the clinician to make immediate notification to the documented emergency contact. All ASA discharged client's emergency contact will be called within the 12 hour timeframe.
The Deputy Regional Director will conduct at least monthly chart audits using our quantitative audit tool, which lists this as a specific item for review.
In addition, the Quality Assurance Department will complete at least quarterly reviews using this same quantitative audit tool. Any findings will result in development of a performance improvement plan to be addressed by the program. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a review of administrative documents submitted, the project failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.The project's last annual financial audit was for the years ending June 30, 2020 and 2019. These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
The Annual Financial Audit for the most recent fiscal year (FY 2020 ? 2021) was not completed in a timely manner due to the delays on the part of the independent certified public accounting firm.
Among these delays were the application of new standards regarding the review of all leased properties (to include all real estate, business machines, and vehicles). This was a very laborious process that will not need to be repeated in the future.
Gaudenzia will obtain a completed financial audit from the independent certified public accounting firm on or before September 30th of 2022.
In order to help ensure that these delays do not occur in the future, the reorganized Fiscal department will begin preparation of all possible documents required for the audit as early as possible in the year.
Leadership in this department reviewed the regulations in DDAP 709.25 on 4/26/22 in order to ensure that all understand the importance of timely completion of the Financial Audit.
The Chief Financial Officer will oversee this process.
9/30/22 |
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of seven client records, the facility failed to document that the client was given the opportunity to request reconsideration of a decision terminating treatment in one applicable record reviewed.Client #4 was admitted on July 20, 2021 and was therapeutically discharged on August 19, 2021. There was no documentation in the record that the client was given the opportunity to request reconsideration of the decision terminating treatment. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
We have a specific form for this in our electronic health record, which is printed and given to the individual.
Our internal workflow documents are being updated to specifically list notification of termination, as well as our internal quantitative audit tool. This will be completed no later than 6/17/22.
Program Director will review the DDAP regulations with all staff in an in-service training no later than 6/17/22.
The Program Director will review all client files at time of discharge to ensure that this has been completed. Any chart missing this notification will be brought to the attention of the clinician to make immediate notification to the individual.
The Deputy Regional Director will conduct at least monthly chart audits using our quantitative audit tool, once updated.
In addition, the Quality Assurance Department will complete at least quarterly reviews using this same quantitative audit tool. Any findings will result in development of a performance improvement plan to be addressed by the program. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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:
(11) 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 records reviewed. Client #1 was admitted on February 17, 2022 and discharged on March 9, 2022. The client record did not contain documentation of follow-up information.Client #2 was admitted on October 14, 2021 and discharged on December 14, 2021. The client record did not contain documentation of follow-up information within 30 days, the timeframe for follow-up established in their policy.Client #4 was admitted on July 20, 2021 and discharged on August 19, 2021. The client record did not contain documentation of follow-up information.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This will be completed for all discharges within 7 days of a referral appointment or 30 days for all other types of discharges using the form developed in our electronic health record for this purpose.
The Program Director will review the policy again with all staff in an in-service training no later than 6/17/22.
The Program Director will review all client files at time of discharge to ensure that this has been completed. Any chart missing this document will be brought to the attention of the clinician to make immediate notification to the documented emergency contact.
The Deputy Regional Director will conduct at least monthly chart audits using our quantitative audit tool, which lists this as a specific item for review.
In addition, the Quality Assurance Department will complete at least quarterly reviews using this same quantitative audit tool. Any findings will result in development of a performance improvement plan to be addressed by the program. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a physical plant inspection, the facility failed to comply with plans of correction that were approved by the Department. A plan of correction for maintaining water temperature in bathrooms below 120 degrees Fahrenheit was submitted and approved by the Department for the October 28, 2020 and June 8, 2021 annual licensing inspections. Maintaining water temperatures in bathrooms under 120 degrees Fahrenheit was again found to be a deficiency in the April 21, 2022 licensing inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In order to ensure that this plan of correction is followed-through with, and to make sure this deficiency isn't repeated, a new, more accurate, digital thermometer was purchased for the facility so that accurate weekly readings by facility staff can be taken and documented on the run sheet. All readings will now be taken using this thermometer during weekly safety runs. Any reading above 118F will be brought to the immediate attention of the Program Director to be addressed with the maintenance department. The Program Director will monitor these readings on a monthly basis to ensure that they are being completed. The Program Director will document this review by initialing and dating the run sheet.
The maintenance staff will also check the hot water temperature on a weekly basis to ensure that the temperature of the hot water does not exceed 120F. This will allow maintenance to make immediate adjustments if the reading does become too close to 120F.
In addition, the water temperature will be monitored by the Quality Assurance Department during quarterly site inspections and findings will be reported to the Program Director to be addressed immediately.
The Quality Assurance department will also review all open plans of correction to ensure full implementation. Any action items found to not have been fully implemented will be brought to the attention of not only the Program Director, but the Deputy Regional Director, and the Executive Director to ensure follow-through."
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