INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on May 21, 2008 and May 22, 2008 by staff from the Division of Drug and Alcohol 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 and a plan of correction is due on June 24, 2008.
|
Plan of Correction
|
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.
|
Observations
Based on a review of administrative material, the facility failed to meet the general training requirements. One of four staff development records did not include documentation of six hours of HIV/AIDS training within one year of employment. Employee # 3 was employed on February 6, 2006 but there was no documentation of the general training requirement as of May 22, 2008.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
|
Observations
Based on an inspection of the facility, the facility failed to ventilate a bathroom. The staff and visitor bathroom on the main level of the facility did not have an operable window or exhaust fan.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
|
Observations
Based on a physical plant inspection, the facility failed to maintain and clean bathrooms at all times. Shower stalls and floors were stained and mold was found in the men's and women's bathrooms which were located on the second and third floors of the facility.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.10 (a) (1) (iii) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(iii) Maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18-inch drop with a well-secured railing.
|
Observations
Based on an inspection of the facility, the facility failed to install handrails on two stairways. Two stairs with more than two steps did not have handrails. One stair way on the main level toward the rear of the building leading to the smoking area did not have a handrail. The basement levels second means of egress did not have a handrail installed.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.32(c)(3) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(3) Inspection of storage areas.
|
Observations
Based on a review of project policy and procedure, the project failed to inspect medication storage areas monthly. Project policy on medication inspections requires a monthly inspection by either the contracting pharmacy or project nurse manager. Based on a review of project medication administration manual and a request to the nurse manager on May 21, 2008 and May 22, 2008 verification of monthly inspections could not be obtained.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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.
|
Observations
Based on a review of client records, the facility failed to document follow-up contact attempts. Three of three client records failed to include documentation of follow-up information. Facility policy requires documentation of client follow-up in seven days after scheduled referral appointments. Client record # 5 was admitted December 18, 2007 and discharged February 27. 2008 with no follow-up completed. Client record #6 was admitted May 16, 2007 and discharged April 28, 2008, but there was no documentation of an attempt to conduct a follow-up. Client record #7 was admitted October 30, 2007 and discharged February 25, 2008 with an appointment scheduled for February 26, 2008, but there was no documentation of a follow-up attempt.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
|
Observations
Based on a review of client records, treatment plans failed to include documentation of work therapy as an integral component of the rehabilitation plan. Four of four client records failed to document work therapy as an integral part of the treatment and rehabilitation plan, specifically client records #1, 2, 3 and 4.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |