INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on May 3, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gaudenzia - New Destiny 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
|
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.
|
Observations
An initial physical plant inspection was conducted on May 2, 2024, to review all common areas for the onsite licensing inspections for multiple licenses at the physical plant address spanning May 2, 2024 through May 3, 2024. The facility failed to keep the yard free of hazards, as a garden box on the path to the children ' s play area had several exposed rusty nails.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Upon discovery of the garden box hazard, the Program Director immediately asked staff to remove the garden box and it was discarded in the facility dumpster the same afternoon.
Ongoing compliance will be monitored via a monthly safety inspection reviewed by the Recovery Support Professional Supervisor.
Completed 5/3/2024 |
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.
|
Observations
Based on a physical plant inspection on May 3, 2024, the facility failed to keep frozen food at or below 0 degrees Fahrenheit. The freezer in the main kitchen/dining room was 18 degrees. Two additional freezers in a second storage area were 9 degrees.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
A work order was submitted to the Maintenance Department requesting freezer inspection and repair, which was completed as appropriate. Additionally, new thermometers were added to the inside of the freezers to assure accurate reading of temperatures.
Ongoing conformance will be monitored by the Recovery Support Professional staff using daily freezer temperature logs and noted on the monthly safety inspection report
Completed 5/31/24 |
705.7 (b) (6) 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:
(6) Store all food items off the floor.
|
Observations
Based on a physical plant inspection on May 3, 2024, the facility failed to store all food items off the floor as two boxes of fruit and four condiment bottles were stored on the floor of the main dining room and kitchen.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Upon discovery of food items in a box sitting on the floor, said items were immediately removed and placed on proper shelving.
The Program Director will assure that all food items are stored properly off the floor.
All staff and clients received a review of proper food storage practices.
The Recovery Support Professional Supervisor will monitor ongoing conformance via review of the daily and monthly safety inspection logs.
Completed 5/3/24 |
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.
|
Observations
Based on a review of fire drill logs from May 2023 through March 2024, the facility failed to ensure that each fire drill log documented the exit route used, whether the smoke detector or fire alarm was operative, or the number of persons in the facility at the time of the drill.
The fire drill logs for July 26, 2023, August 19, 2023, and August 28, 2023, did not document the exit route used.
The fire drill logs for August 23, 2023, October 11, 2023, and each drill between November 2023 and March 2024, did not document whether the smoke detector of fire alarm was operative.
The fire drill logs for July 11, 2023, August 23, 2023, and October 30, 2023, did not document the number of persons in the facility at the time of the drill.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Program Director will assure that fire drill logs are fully completed including the exit route used, whether the smoke detector or fire alarm was operative, and the number of persons in the facility at the time of the drill.
All staff were retrained on proper completion of fire drill logs.
The Recovery Support Professional Supervisor will monitor ongoing compliance via review of the monthly fire drill reports and safety reports.
Completed 5/31/24 |
705.11 (2) (iii) LICENSURE Child care.
705.11. Child care.
(2) Interior space. The residential facility shall:
(iii) Maintain protective caps over each electrical outlet.
|
Observations
Based on a physical plant inspection on May 3, 2024, the facility failed to maintain protective caps over each electrical outlet as one outlet in the third-floor lounge and one outlet in a second-floor office, did not have protective caps.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Program Director will assure that protective caps are maintained over each electrical outlet.
All staff were reminded of the regulation and additional caps were purchased and placed on outlets as needed.
The Recovery Support Professional Supervisor will monitor ongoing compliance via review of daily and monthly facility safety inspection logs.
Completed 5/31/24 |
705.11 (2) (iv) LICENSURE Child care.
705.11. Child care.
(2) Interior space. The residential facility shall:
(iv) Secure all hazardous and poisonous substances and materials with safety latches or locks.
|
Observations
Based on a physical plant inspection on May 3, 2024, the facility failed to secure all hazardous and poisonous substances and materials with safety latches or locks. A bathroom on the third floor contained a cleaning product that was not secured with safety latches or locks.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Program Director will assure that all hazardous and poisonous substances and materials are secured with safety latches or locks.
The cleaning product found in a third floor bathroom was removed by staff and placed in the secure locked chemical storage cabinet.
The chemical storage protocols were reviewed with all staff and clients.
Ongoing compliance will be monitored by the Recovery Support Professional Supervisor via daily and monthly safety inspection logs.
Completed 5/8/2024 |
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.
|
Observations
Based on a review of personnel records, the facility failed to ensure that annual written individual staff performance evaluations, were reviewed and signed by the employee per the facility's policy and procedure manual in four of four applicable personnel records reviewed. The facility's policy and procedure manual states that the annual job performance evaluations are due at the beginning of each calendar year. Project staff indicated evaluations specifically are to be completed and signed by February 1 each year.
Employee # 1 was hired as the Project Director on September 9, 2019 and is current in that position. The annual written staff performance evaluation was due to be reviewed and signed by the employee by February 1, 2024, however, it was not signed by the employee until February 28, 2024.
Employee # 3 has been in the position of Clinical Supervisor since February 25, 2020. The annual written staff performance evaluation was due to be reviewed and signed by the employee by February 1, 2024, however, it was not signed by the employee until February 12, 2024.
Employee # 4 has been in the position of counselor since June 13, 2022. The annual written staff performance evaluation was due to be reviewed and signed by the employee by February 1, 2024, however, however, it was not signed by the employee until February 15, 2024.
Employee # 5 has been in the position of counselor since November 16, 2009. The annual written staff performance evaluation was due to be reviewed and signed by the employee by February 1, 2024, however, however, it was not signed by the employee until February 15, 2024.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Deputy and Program Directors will meet with facility managers to ensure that all personnel records will include a written annual staff performance evaluation, reviewed, and signed by the employee in accordance with agency policy by February 1 each year, including but not limited to the Project Director and facility staff.
Facility supervisors will begin evaluations with direct supervisees in early January and submit completed documentation by February 1 each year.
Training will be provided as needed.
The Deputy and Program Directors and Human Resources will monitor weekly the facility evaluation progression in January to assure conformance.
|
709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
|
Observations
Based on a review of seven client records, the facility failed to follow their policy and procedures related to medication administration and recordkeeping in four records reviewed. The facility policy indicates that the nurse or designated trained staff member who conducts the " medication run " must sign the medication sheet with his/her initials. Additionally, the facility policy indicates that staff will document on the medication administration record (MAR) the reason a medication was not given.
Client # 1 was admitted on June 16, 2023 and was discharged on August 4, 2023. The record did not contain MAR records for the month of July 2023 and the record contained evidence that medications were prescribed.
Client # 2 was admitted on July 27, 2023 and was discharged on November 26, 2023. The record did not contain MAR records for the months of July, August, September, or October 2023 and the record contained evidence that medications were prescribed.
Client # 4 was admitted on August 16, 2023 and was discharged on February 26, 2024. The record did not contain MAR records for the months of August, September, October 2023, or February 2024, and the record contained evidence that medications were prescribed.
Client # 6 was admitted on March 8, 2024 and was active at the time of the inspection. The MAR did not document the reason medications were not administered on April 20, 2024 or April 21, 2024.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Program Director will assure that medication administration policies and procedures are followed, including the documentation in the medication administration record of reasons for medication not given and staff signature/initials when conducting "medication runs".
Medication documentation protocols were reviewed and staff training provided as needed.
Ongoing conformance will be monitored via monthly record audits completed by the Continued Quality Improvement Dept and Program Managers.
Completed 5/31/24 |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
|
Observations
Based on the review of the unusual incident logbook, the project failed to file a written unusual incident report with the Department within three business days following an unusual incident involving the presence of police, fire, or ambulance personnel.
There was documentation of the presence of police personnel onsite on October 29, 2023 and ambulance personnel onsite on May 29, 2023 and November 18, 2023; however, there was no documentation that written unusual incident reports were ever filed with the Department.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
The Program Director will assure that the facility files a written unusual incident report with the Department within three business days following an unusual incident involving the presence of police, fire, or ambulance personnel.
The incident reporting policies and procedures were reviewed with staff including required notification of the Department.
The Clinical Supervisor will submit the identified outstanding incident reports to the Dept by 6/22/24.
Ongoing compliance will be monitored monthly by the Administrative Coordinator in conjunction with Continuous Quality Improvement activities and safety meeting.
|
709.51(b)(3)(iii) LICENSURE Personal History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
|
Observations
Based on a review of client records and the facility's policies and procedures, the facility failed to document a client's personal history within five days of admission, per facility policy, in two of five applicable records reviewed.
Client # 4 was admitted on August 16, 2023 and was discharged on February 26, 2024. The personal history was not completed until September 8, 2023.
Client # 8 was admitted on October 13, 2023 and was discharged on January 9, 2024. The personal history was not completed until October 23, 2023.
These finding were discussed with facility staff during the licensing process.
|
Plan of Correction
The Clinical Supervisor and Program Director will assure that a client's personal history is documented within 5 days of admission per organization policy.
The clinical workflow and policy on history collection was reviewed with counselors. Training will be provided as needed.
Ongoing conformance will be monitored via monthly record audits conducted by program managers and the Continuous Quality Improvement Department
Completed 5/22/2024 |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of client records and the facility's policies and procedures, the facility failed to document a psychosocial evaluation within five days of admission, per facility policy, in three of five applicable records reviewed.
Client # 3 was admitted on October 9, 2023 and was discharged on January 25, 2024. The psychosocial evaluation was not completed until November 16, 2023.
Client # 4 was admitted on August 16, 2023 and was discharged on February 26, 2024. The psychosocial evaluation was not completed until September 25, 2023.
Client # 8 was admitted on October 13, 2023 and was discharged on January 9, 2024. The record did not contain a psychosocial evaluation.
These finding were discussed with facility staff during the licensing process.
|
Plan of Correction
The Program Director and Clinical Supervisor will assure the documentation of a psychosocial evaluation within 5 days of admission per facility policy.
The clinical workflow and related policy was reviewed with counselors and training provided as needed.
The Continuous Quality Improvement Dept and program managers will monitor ongoing compliance via monthly record audits.
Completed 5/22/24 |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
|
Observations
Based on a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every 30 days in three of five applicable records reviewed.
Client # 4 was admitted on August 16, 2023 and was discharged on February 26, 2024. The individual treatment and rehabilitation plan was completed on September 15, 2023, and the treatment plan update was due to be completed by October 15, 2023; however, the treatment plan update was not completed until November 15, 2023.
Client # 5 was admitted on January 29, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on February 29, 2024, and the treatment plan update was due to be completed by March 29, 2024; however, no additional treatment plan updates were completed prior to the inspection.
Client # 7 was admitted on January 17, 2024 and was active at the time of the inspection. A treatment plan update was completed on March 15, 2024, and the next treatment plan update was due to be completed by April 15, 2024; however, no additional treatment plan updates were completed prior to the inspection.
These finding were discussed with facility staff during the licensing process.
|
Plan of Correction
The Clinical Supervisor and Program Director will ensure that treatment and rehabilitation plans are reviewed and updated at least every 30 days.
The clinical workflow and related policy was reviewed with counselors, tracking strategies identified, and training provided as needed.
Ongoing compliance will be monitored by the Continuous Quality Improvement Dept and program managers via monthly record audits.
Completed 5/22/2024 |