INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and a complaint investigation conducted on May 27, 2009 and May 28, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Inc. 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 and a plan of correction is due on June 24, 2009.
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Plan of Correction
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705.2 (1) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
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Observations
Based on an inspection of the physical plant, a review of incidents reports, extermination reports and interviews with staff and residents the facility failed to maintain the residential structure so as to be free from any danger to health and safety.
Findings:
An inspection of the physical plant was conducted on May 27, 2009 between the hours of 1:00 P.M. and 2:00 P.M., and extermination reports were reviewed on May 27, 2009. Incidents reports for the period February 2009 through May 2009, shift log reports for the period March 2009 through May 2009 and interviews with three staff and four residents on May 28, 2009 demonstrated that construction and renovations at the facility have presented a danger to staff, residents and visitors. Open ceilings and walls with exposed plumbing and wiring were observed in the admissions area, kitchen area, food storage area and the dining room. Renovations and construction have not been completed in the kitchen, dining room, admission and administrative areas. Plywood was taped to the floor in the Detoxification unit on the first floor. An incident report reviewed on May 28, 2009 verified that a child had tripped on plywood. An incident report of April 23, 2009 verified a resident attempted to catch a rodent, was bitten and taken to the emergency room. Shift log reports verified that on April 20, 2009 and April 27, 2009 a resident complained of insect bites. A log report on April 5, 2009 verified that rodents have been found in traps located at five different locations in the facility. Shift log entries during the period of March 2009 and May 2009 documented problems with entrance doors left ajar with rugs, shims and other items.
Ten commercial pest extermination services have been required during the period on February 1, 2009 through May 21, 2009. Both staff and residents interviewed on May 28, 2009 indicated the renovations and construction efforts have been a distraction to counseling, dietary and support activities.
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Plan of Correction
Plywood utilized on carpeting of Detox area has been removed as of 6/25/09. It should be noted that there was an error in the cite indicating there was an incident report regarding a fall by a child. A New Destiny Staff person tripped on the plywood and the next day the plywood was repaired and there have been no further falls or injuries. Ceiling tiles missing in both programs will be replaced by July 1st by the Central Region Plant Manager. The Plant Manager will also delineate areas which are out-of-bounds to staff and/or clients both inside and outside the building by marking those areas with appropriate signs and construction tape. When an area is under demolition or construction, program activities and clients are directed into a safe area of the building.
Problems caused by workmen propping open doors, both interior and exterior to the building was addressed in the bi-weekly construction meeting and was addressed again in the June 25, 2009 meeting. Facility staff will continue to monitor proper closure of these doors during house runs and at various times throughout the 24-hour work day to ensure safety. They will continue to document findings and report to the Program Director. We are not experiencing any problems with this, there is no more propping of doors.
The rodent problem has abated with with advent of warmer weather as well as the installation of bait traps around the perimeter of the building. Due to the nature of the program only sticky traps could be utilized within the building. It should be noted that each program is visited separately by Ehrlich Pest Control, therefore, there were five visits to Fountain Springs and five visits to New Destiny and that three of each of the five visits was for routine pest control. In an attempt to be pro-active, both programs independently contacted Ehrlich for additional pest control services when mice were sited. At no time were residents required or expected to empty the sticky traps. One resident at Fountain Springs due to her desire to see no animal harmed did attempt to release a mouse from a sticky trap and was either bitten or scratched for her effort. After this incident the client was addressed by the Program Director. She was directed not to tamper with the traps and was educated on both health and safety issues related to such action.
It needs to be noted that we have had a maintenance contract with Ehrlich for pest control since the opening of Fountain Springs in 1991. Fountain Springs and New Destiny do not have a pest infestation and Ehrlich continues to service our facilities on a monthly basis.
In regard to insect bites, there were two reports of a bite reported by the same client and no additional complaints from any client or staff.
On 7/7/2009 notification was received of a projected completion date of 8/31/2009 for the renovation projects at Fountain Springs/New Destiny.
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709.11-709.18 LICENSURE Subchapter B. Licensing Procedures
Subchapter B. Licensing Procedures
709.11. Application for license.
(a) Persons, partnerships, corporations, or other legal entities intending to provide drug and alcohol treatment services shall apply for a license from the Department. Application shall be made using forms and procedures prescribed by the Department.
(b) The license shall expire 1 year from the date of issuance. Prior to the expiration of the current license, the Department will notify the facility of the date for an annual on-site inspection for renewal of license.
(c) The Department will notify the appropriate SCA of applications for and issuance of a license to any facility or individual within the SCA's area of responsibility.
709.12. Full licensure.
(a) A license to operate the facility will be issued when, after an on-site inspection by an authorized representative of the Department, it has been determined that requirements for licensure under this chapter, have been met.
(b) A license will be issued to the owner of a facility and will indicate the name of the facility, the address, the date of issuance, and the types of activities the facility is authorized to provide.
(c) The current license shall be displayed in a public and conspicuous place in the facility.
709.13. Provisional licensure.
(a) The Department will issue a provisional license, valid for a specific time period of no more than 6 months when the Department finds that a facility:
(1) Has substantially, but not completely, complied with applicable requirements for licensure.
(2) Is complying with a course of correction approved by the Department.
(3) Has existing deficiencies that will not adversely alter the health, welfare or safety of the facility's clients.
(b) Within 15 working days of receipt of the deficiency report, facility staff shall submit a plan to correct deficiencies noted during the site visits.
(c) A provisional license may be renewed no more than three times.
(d) A regular license will be issued upon compliance with this part.
709.14. Restriction on license.
(a) A license applies to the person, the named facility, the premises designated therein and the activities noted, and is not transferable.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(1) Change in ownership.
(2) Change in name of the facility.
(3) Change in location of the facility.
(4) Change in activity/discontinuance of an activity.
(5) Change in authorized maximum capacity.
(6) Closing of facility.
(c) Failure to notify the Department under subsection (b) will result in automatic expiration of the license.
709.15. Right to enter and inspect.
(a) An authorized representative of the Department has the right to enter, visit, and inspect a facility licensed or applying for a license under this chapter.
(b) The authorized Department representative shall have full and free access to the records of the facility and its clients.
(c) The authorized Department representative has the right to interview clients as part of the visitation and inspection process.
709.16. Notification of deficiencies.
(a) The authorized Department representative will leave appropriate Department forms with the facility director to address areas of noncompliance with the standards.
(b) These forms shall be completed and submitted to the Division of Licensing within 15 working days after the site visit.
(c) A license may not be issued until a plan of action has been approved by the Department.
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(1) Failure to comply with a directive issued by the Department.
(2) Violation of, or noncompliance with, this chapter.
(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.
(4) Gross incompetence, negligence or misconduct in the operation of the facility.
(5) Fraud, deceit, misrepresentation or bribery in obtaining or attempting to obtain a license.
(6) Lending, borrowing or using the license of another facility.
(7) Knowingly aiding or abetting the improper granting of a license.
(8) Mistreating or abusing individuals cared for or treated by the facility.
(9) Continued noncompliance in disregard of this part.
(10) Operating a facility that, by nature of its physical condition, endangers the health and safety of the public.
(b) If the Department proposes to revoke or refuse to issue a license, it will give written notice to the facility by certified mail, stating the following:
(1) The reasons for the proposed action.
(2) The specific time period for the facility to correct deficiencies.
(c) If the facility does not correct the deficiencies within the specified time, the Department will officially notify the licensee that it shall show cause why its license should not be revoked under 1 Pa. Code Subsection 35.14 (relating to orders to show cause), and that it has a right to a hearing authorized by the Department on this question. A request to the Department for a hearing shall be filed, in writing, within 30 days of receipt of the show cause order.
(d) Subsection (c) supplements 1 Pa. Code Subsection 35.14.
709.18. Hearings.
(a) The Department will convene and conduct a show cause hearing for a facility under 1 Pa. Code Subsection 35.37 (relating to answers to orders to show cause) and this chapter.
(b) An administrative hearing held under this section shall be conducted under 1 Pa. Code Part II (relating to general rules of administrative practice and procedure).
(c) The Department may institute appropriate legal proceedings to enforce compliance with this chapter.
(d) This section supplements 1 Pa. Code Part II.
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Observations
Based on a review of facility daily shift logs, incident reports and an interview with the facility director, the facility failed to follow a directive issued by the Department by not reporting unusual incidents as outlined in Licensing Alert - Reporting of Unusual Incidents issued May 1997. The alert requires verbal notification within 24 hours and written notification within 72 hours for a resident hospitalization.
Findings:
Based on a review of the shift logs on May 27, 2009 for the period of April 1, 2009 through May 27, 2009 the agency failed to report two hospitalizations due to illness that occurred when a resident was at the facility and under the supervision of the facility. On May 1, 2009 and May 21, 2009 a resident was transported to the St. Catherine's emergency room and subsequently admitted. A review of the facility incident reports for the period of March 2009 through May 2009 and an interview with the facility director on May 28, 2009 confirmed that the facility did not provide verbal notification to the Division within 24 hours and a written report to the Division within 72 hours.
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Plan of Correction
All hospitalizations due to illness that occur when a resident is at the facility and under the supervision of the facility will be reported verbally to the Department of Health Division of Licensing within twenty-four (24) hours and in writing within seventy-two (72) hours.
The Program Director will address staff in a mandatory staff meeting by July 9, 2009. At this meeting, the Gaudenzia Policy and Procedure for Incident Reports will be reviewed as well as the Unusual Incident Reporting required by the Department of Health (BDAP). All documents will be reviewed and staff will sign-off to indicate that they are familiar with the policy. The Program Director will directly monitor compliance for a period of ninety (90) days; this will also include monthly reporting to the Gaudenzia Safety Committee. |