INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 27, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gaudeniza Inc. 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 five personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that two employees received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #4 was hired as a counselor on March 9, 2020 and was due to have the communicable disease trainings no later than March 9, 2021. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee #5 was hired as a counselor assistant on July 8, 2019 and was due to have the communicable disease trainings no later than July 9, 2020. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Employee # 4 is no longer employed with Gaudenzia as of 4-30-21. Employee # 5 attended HIV/Aids on May 7, 2021 as well as TB/STD's on 2-13-20 however, due to clinical failure to follow training tracking processes, a copy of the certificate was not present for the inspection. The 2-13-20 certificate is now on site and in employee # 5's personnel chart. Staff training requirements and timeline will be reviewed during the monthly management meeting and will be monitored by the Clinical Supervisor and Program Director for ongoing compliance. |
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the fire drill logs from July 2020 until April 2021, the facility failed to ensure that alternate exit routes were used during fire drills as all fire drill logs documented only the front exit was being used.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
- An all staff meeting will be held on 5-21-21. Staff will be directed to utilize two different exits during their monthly fire drills while guiding all occupants in the facility safely out of the designated exits. These drills will be documented monthly on the fire drill grid by facility staff and reviewed by the Program Director as well as reported monthly in the Safety Committee meetings. |