INITIAL COMMENTS
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This report is a result of an on-site licensure inspection conducted on May 16 - 17, 2012 by staff from the Division of Drug and Alcohol Program Licensure.
Based on the findings of the on-site inspection, Gaudenzia Washington 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(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to document an individual training plan in accordance with facility policy in one of two records.
The findings include:
The project policy states: "In January of each year, the Program Director, in conjunction with the Supervisor, will conduct needs assessments, via individual training plan forms for all employees, to determine what topics and areas of training should be provided during the coming year."
On May 7 through May 9, 2012, employee # 1's personnel record was reviewed.
The project failed to develop an individual training plan annually in accordance with policy.
Employee # 1 has been the Project Director since 1988.
Per policy, training plans will be conducted in January of each year.
The facility failed to document an individual training plan in January for employee # 1.
This is a repeat citation. The Project was previously cited for noncompliance with this standard during the 2011 licensure inspection.
The findings were reviewed with the human resources staff.
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Plan of Correction
The Training Department will ensure that an individual training plan is developed and documented for all employees within required timeframes.A reminder of the January 31st deadline for completion will be forwarded to all managers during the 1st week of December. In addition, the Training Department will coordinate with the Executive Assistant to ensure that development of an Individual Traning Plan for the Project Director is a specific agenda item during the Project Director's meeting with the Chairman of the Board during the month of December. A current signed Individual Training Plan is presently in the Project Director's file. Individual Training Plans will be completed for all employees by January 31, 2013 as per our policy
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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
On May 16, 2012 copies of the staff CPR and First Aid cards and the April and May work schedule as provided by the facility were reviewed.
Findings:
Based on the work schedule and the CPR and First Aid cards provided by the facility, the facility failed to provide CPR coverage for the following time frames on the following dates:
5 PM to 11:30 PM on April 2, 3, 4, 5, 6, 9, 12, 19, and 24, 2012 and May 2, 3, 4, 9, 10, 16, and 17, 2012.
3:30 PM to 11:30 PM on April 1, 7, 8, and 21. The facility also did not provide CPR coverage from 3:30 PM to 11:30 PM on May 12 and 13, 2012.
The Facility Director confirmed the findings.
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Plan of Correction
The program Administrator will review the CPR cards on the first day of December in each year to determine which staff person needs to attend CPR trainings based on card expiration dates. This will be done to ensure that all staff working in the facility maintain current CPR certification. The staff person whose CPR certfication expired went to CPR training on 5/21/12 at Staffing Plus, in Haverford, PA. This staff person attended the CPR class and recieved CPR documents that says the staff person is currently CPR certified. The employee whose CPR certificate had expired had her shift / work scheduled changed. She went from working 3:30pm to 11:30 pm to working 7:30 am to 3:30pm. On 5/18, 5/19 and 5/20/12 this employee worked the 1st shift along with other staff who have CPR certifications. The Program Director and Clinical Supervisor worked additional hours to cover shift with staff person on 5/17/12. |
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 observation during a physical plant inspection, the facility failed to keep cold food at or below 40 Fahrenheit (F) and frozen food at or below 0 F.
The findings include:
On May 17, 2012 a physical plant inspection was conducted at approximately 1:30 PM.
The facility failed to keep cold food at or below 40 F, and frozen food at or below 0 F.
It was observed that facility's one refrigerator had a temperature above 40F. The thermometer in the refrigerator displayed a temperature of 50 degrees Fahrenheit.
It was observed that one out of two freezers had a temperature above 0F. The thermometer in the freezer displayed a temperature of 20 degrees Fahrenheit.
The Facility Director confirmed that the refrigerator and freezer temperatures exceeded 40 degrees and 0 degrees respectively.
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Plan of Correction
The old unit(refrigerator)was replaced. A new refrigerator was delivered to the facility on 6/30/2012. There is a thermometer built into the new refrigerator unit as well as a new thermometer that hangs from one of the racks.House manager staff will maintain a daily log to ensure that the temperture in the refrigerator doesn't exceed 40 F.
The Adminisrative Coordinator will contact the building maintenance man every six months to ensure that the refrigerator unit is working properly. The new unit is a refrigerator, it does not include a freezer compartment. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of administrative documentation, the project failed to document an independent annual audit of financial activities associated with the project's drug/alcohol abuse services by the end of the fiscal year.
The findings include:
On May 7 through May 9, 2012, the project's administrative records were reviewed for a financial audit following the end of their fiscal year. The project's fiscal year runs from July 1 through June 30. The financial audit was to be documented by the end of the fiscal year; the financial audit for this period was not documented at the time of review.
Administration confirmed that the financial audit had not been documented following the end of the fiscal year.
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Plan of Correction
The Director of Finance and Accounting will coordinate with the external independent public accountant to ensure that all future financial audits are completed within required timeframes. This will be completed by December 31st, 2013 as per our policy. |