INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 30, 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 Focus House 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)(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.
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Observations
Based on a review of two personnel records and the Staffing Requirements Facility Summary Report, the facility failed to ensure that three of three applicable employees received 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 within the regulatory timeframe.
Employee # 2 was hired as the Facility Director on October 25, 2021 and was due to have the communicable disease trainings no later than October 25, 2023. However, the personnel record contained no documentation of the completion of the HIV/AIDS or TB/STD trainings as of the date of the inspection.
Employee # 3 was hired as a support staff member on August 16, 2021 and was due to have the communicable disease trainings no later than August 16, 2023. However, the personnel record contained no documentation of the completion of the HIV/AIDS or TB/STD trainings as of the date of the inspection.
Employee # 4 was hired as a support staff member on February 1, 2021 and was due to have the communicable disease trainings no later than February 1, 2023. However, the personnel record contained no documentation of the completion of the HIV/AIDS or TB/STD trainings as of the date of the inspection.
This is a repeat citation from the May 18, 2023 annual licensing renewal inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The mandatory communicable disease training is an available DDAP course on HIV which is a six-hour course available virtually. This has been identified as the required H.I.V. training to be taken by all the staff of Focus House. An email has been sent to the staff indicating that this training has to be completed within 30 days. Going forward, completing the H.I.V., and TB/STD trainings will be implemented during the onboarding process. During the first 48 hours, new hires primarily complete all the trainings required. The DDAP trainings for these particular areas will be implemented by the program supervisor and reviewed by the same following onboarding. Should the current staff fail to complete these training courses within this 30-day period, the program supervisor will issue a formal corrective action. |
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 a physical plant inspection on May 30, 2024, the facility failed to ensure that bathrooms had hot water under pressure, as the shower and sink in the bathroom of Bedroom # 2 did not have hot water under pressure.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Bathroom number two has an issue that must be addressed by the contractor. There has been a work order submitted on several occasions. The facility's maintenance contacted the contractor that did the work. The contractor came to the facility to review the work and stated that his team would return as soon as they completed another job. There is no way of ensuring that a contractor properly completes a job for which they are paid. This is an issue that is a one-of-a-kind issue that was not reported to the program supervisor until after the contractor left the facility for a new job. The Facilities Maintenance staff will have to observe private contractors going forward. The Facilities Maintenance Manager would be responsible for ensuring that the proper corrective action is taken. Going forward, the recovery support professionals will conduct a facilities inspection to ensure that everything is in working order or submit a maintenance request. |
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 May 30, 2024, the facility failed to keep frozen food at or below 0 degrees Fahrenheit, as the freezer in the basement was 21 degrees.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The thermometer reading on the day of inspection was approximately 20 degrees. It appeared that the door was the issue. A work order was put in for the repair of the door, which was repaired on May 31, 2024. However, the freezer is now registering at 7 degrees. The Program Supervisor submitted a work order for Americooler to come service the freezer. Going forward, the supervisor is responsible for checking the refrigerator log daily. |
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 client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients. The facility failed to follow their policy related to Against Staff Advice (ASA) discharges of calling the Emergency Contact within twelve hours in one of one applicable record reviewed.
Client # 4 was admitted on October 12, 2023 and discharged Against Staff Advice (ASA) on October 28, 2023. The record contained documentation that the emergency contact was not called until October 31, 2023.
This is a repeat citation from the May 18, 2023 annual licensing renewal inspection.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
Recovery support professionals didn't have access to the residents' charts. We have created a sheet with all the residents' emergency contacts that will be maintained in the communication log for the recovery support professionals. One has also been posted in the medication room as a backup. On the next business day, all aspects of the incident report will be reviewed by the Program Supervisor and/or the case manager on the next business day. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of seven client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information prior to disclosing information in one record reviewed.
Client # 6 was admitted on April 30, 2024 and was active at the time of the inspection. The record contained documentation of contact with a parole officer on May 2, 2024, to whom the record contained no informed and voluntary consent to release information form signed by the client.
This is a repeat citation from the May 18, 2023 and May 4, 2022 annual licensing renewal inspections.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
One of the entry questions for individuals accepted at Focus House will be whether they know if they are on probation or not. If so, a consent for Probation and Parole will be completed. In the case of client #6, the resident was present when the probation officer entered the program supervisor's office. As for the consents, more language was added following the last inspection to cover all the information required. Additional language will be added to cover what is requested. The Program Supervisor is responsible for the signing of consents upon arrival to the program. He will ensure that all consents are signed in advance of any sharing of information. |
709.28 (c) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of seven records, the facility failed to ensure that informed and voluntary consent to release information forms included the specific information to be disclosed in seven records reviewed.
Client # 1 was admitted on October 4, 2023 and was discharged on November 2, 2023. The record contained consent to release information forms to the funding source and two government agencies signed by the client on October 4, 2023, that were missing the specific information to be disclosed.
Client # 2 was admitted on August 10, 2023 and was discharged on May 21, 2024. The record contained consent to release information forms to the funding source and two government agencies signed by the client on August 10, 2023, and again on January 11, 2024, that were missing the specific information to be disclosed.
Client # 3 was admitted on August 11, 2022 and was discharged on September 14, 2023. The record contained consent to release information forms to the funding source and two government agencies signed by the client on July 7, 2023, that were missing the specific information to be disclosed.
Client # 4 was admitted on October 12, 2023 and was discharged on December 29, 2023. The record contained consent to release information forms to the funding source and two government agencies signed by the client on October 13, 2023, that were missing the specific information to be disclosed.
Client # 5 was admitted on February 22, 2024 and was active at the time of the inspection. The record contained consent to release information forms to the funding source and two government agencies signed by the client on February 22, 2024, that were missing the specific information to be disclosed.
Client # 6 was admitted on April 30, 2024 and was active at the time of the inspection. The record contained consent to release information forms to the funding source and two government agencies signed by the client on April 30, 2024, that were missing the specific information to be disclosed.
Client # 7 was admitted on June 8, 2023 and was active at the time of the inspection. The record contained consent to release information forms to the funding source and two government agencies signed by the client on June 8, 2023, and again on January 31, 2024, that were missing the specific information to be disclosed.
This is a repeat citation from the May 18, 2023 annual licensing renewal inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The consents have had more language added following the last inspection to cover all the information required. Additional language will be added to cover what specific information is to be requested. The Program supervisor is responsible for adding the language and has already initiated the change following receiving information from the inspector. The Program Supervisor is responsible for the signing of consents upon arrival to the program. He will ensure that all consents are signed in advance of any sharing of information. All consents will be changed by the Program Supervisor in conjunction with each resident of the facility. |
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.
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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 six of seven applicable records reviewed. The facility policy indicates that staff will document on the medication administration record (MAR) the reason a medication was not given. Additionally, medication administration forms will include date and time of administration.
Client # 1 was admitted on October 4, 2023 and was discharged on November 2, 2023. The MAR did not document the reason medications were not administered on October 4, 2023 through October 31, 2023.
Client # 2 was admitted on August 10, 2023 and was discharged on May 21, 2024. The MAR in February 2024 did not document whether a medication was taken or the reason it was not administered on February 14-17, 2024, February 20-24, 2024, and February 26-28, 2024. The MAR in April 2024 did not document whether a medication was taken or the reason it was not administered on April 4, 2024, April 6-7, 2024, April 9-10, 2024, April 13, 2024 and April 15, 2024. The record did not contain MAR records for August through December 2023 and there was evidence that medications were administered during this period.
Client # 3 was admitted on August 11, 2022 and was discharged on September 14, 2023. The record did not contain MAR records for July through September 2023 and there was evidence that medications were administered during this period.
Client # 4 was admitted on October 12, 2023 and was discharged on December 29, 2023. The record did not contain MAR records for October 2023 and there was evidence that medications were administered during this period.
Client # 5 was admitted on February 22, 2024 and was active at the time of the inspection. The record contained a MAR that was not labeled with the complete date of administration to include the month. Additionally, the MAR did not document the reason medications were not administered on March 11, 2024, March 24, 2024, March 25, 2024, and March 27, 2024.
Client # 7 was admitted on June 8, 2023 and was active at the time of the inspection. The record did not contain MAR records for June through December 2023 and there was evidence that medications were administered during this period.
This is a repeat citation from the May 18, 2023 annual licensing renewal inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The process for review of the MAR has been changed to add the case manager. All MAR sheets will be reviewed by the oncoming shift to highlight any deficiencies by the prior shift. The Program Supervisor will review the MAR sheets weekly. At the end of the month, the MAR sheets will be submitted to the case manager to ensure that they are properly filed away. The Program Supervisor will review each process. |
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.
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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 ambulance personnel on October 29, 2023; however, there was no documentation that a written unusual incident report was ever filed with the Department.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The staff have been provided with all the required reports to be filed should an incident occur. There has been an explanation of each of the reports to the staff, and examples have been provided to each of the staff members to include emergency contacts. Reports are submitted to the Program Supervisor for review. If an incident occurs on the weekend, the Program Supervisor will review the incident reports upon his return. Currently, all staff must complete an incident report that was given as an example to ensure that staff become proficient at completing the reports. A report for October 2023 will be submitted by the Program Supervisor. |
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 review of client records, the facility failed to comply with plans of corrections that were approved by the Department.
A plan of correction for obtaining client signed consent to release information forms prior to disclosures of information was submitted and approved by the Department for the May 18, 2023 and May 4, 2022, annual licensing inspections. Obtaining client signed consent to release information forms prior to disclosing information was again found to be a deficiency in the May 30, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Supervisor has ultimate responsibility to ensure plans of corrections are implemented. To ensure there are no repeated citations, the facility has obtained detailed information from the DDAP Licensing Specialist to clarify regulations and has developed plans to train staff, revise admission procedures, and regularly monitor the implementation of plans of corrections moving forward. |