INITIAL COMMENTS
|
This report is a result of an on-site complaint investigation conducted on November 6, 2019 by staff from the Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the on-site complaint investigation, Gaudenzia Inc. Winner Co-Occurring Women & Children Program was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
|
Plan of Correction
|
705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
|
Observations
During the physical plant tour, the facility failed to ensure that all trash containers were covered.
The one dumpster located in the back yard failed to have the required trash cover.
The finding was discussed with the facility during the complaint investigation.
|
Plan of Correction
Program Director will review PO13 standards for ensuring that all trash containers are covered and all dumpster lids are closed. This review will occur 1x weekly during community meetings beginning on 11/18/19 and on-going.
During hourly house runs, staff will assure that all dumpster lids are closed and ensure all trash cans have appropriate lids.
All issues and concerns regarding PO13 will be immediately reported to the Program Director 1x daily. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
|
Observations
During the complaint investigation, the facility failed to ensure that counseling session could not be heard.
The Program Representative Supervisor was in an office, that was located by the group room and during their group session the session could be over heard.
The finding was discussed with the facility during the complaint investigation.
|
Plan of Correction
Program Director will meet with the management staff to develop and implement a plan to address PO21.The management/maintenance team will identify physical plant/construction modifications needed to provide additional privacy in the group room area beginning on 12/16/2019.
Development plan will be identified and obtained beginning on 12/16/2019.
Program Director will assure compliance with PO21 beginning on 2/15/2020
|
705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
|
Observations
During the physical plant tour, the facility failed to provide privacy in toilets by doors.
Boys restroom located on the 3rd floor was missing a door in one of the bathroom stalls. Additionally, one of the showers located in the same restroom, failed to have a slip resistant mat in one of the showers.
The finding was discussed with the facility during the complaint investigation.
|
Plan of Correction
Program Director was able to follow-up on the status of the previous Oder for the Stall door located on the 3rd floor. This action was completed on 11/6/2019. Program director will assure the delivery and installation of the stall door is installed upon delivery on or prior to 12/12/2019.
Program Director was able to address and correct observations noted in PO61 on 11/6/2019. Slip resistant mats were placed in the shower located on the third floor, boys bathroom.
House Manager Supervisor will assure that house runs are completed daily and all required slip resistant mats are located in all showers. All issues with compliance will be immediately reported to the Program Director to assure on-going compliance. These action were taken effective 11/7/2019. |
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
During the physical plant tour, the facility failed to ensure that each bathroom was functional.
There were missing tiles, which can cause a tripping hazard for client's and their children.
The finding was discussed with the facility during the complaint investigation.
|
Plan of Correction
Program Director reviewed safety hazards identified in the 2nd floor bathroom on 11/7/2019 with the maintenance department.
Program Director will assure that tiles are replaced in the 2nd floor bathroom and compliance is obtained by 1/20/2020. |
705.7 (b) (4) 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:
(4) Ensure that storage areas for foods are free of food particles, dust and dirt.
|
Observations
During the physical plant tour, the facility failed to ensure that the food storage areas are free from food particles, dust and dirt.
Behind the serving station in the dining room had food, trash and standing water which needed to be cleaned.
The findings were discussed with the facility during the complaint investigation.
|
Plan of Correction
Program Director and facility cook assured that the food storage areas was free from food, particles, dust and dirt during immediately after observations were noted on 11/6/2019.
Facility cook will conduct daily inspections of the food storage area and make any necessary corrections to assure compliance with PO77 beginning 11/6/2019 and on-going.
|
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
|
Observations
During the physical plant tour, the facility failed to ensure that all exits are unobstructed. The exit in the basement separating the laundry room and child care room was blocked by a child changing table.
The finding was discussed with the facility during the complaint investigation.
|
Plan of Correction
Director was able to ensure that the fire exit was unobstructed during the inspection on 11/06/2019.
Childcare supervisor will conduct daily inspections of the childcare department to assure compliance with P105 one time daily between the hours of 9am and 10am. All compliance issues will be immediately addressed and reported to the Program Director who will assure on-going compliance beginning 11/7/19. |
705.10 (a) (1) (v) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(v) Light interior exits and stairs at all times.
|
Observations
During the physical plant tour, the facility failed to ensure that all exits are always lighted. The exit door leading into the basement at the top of the stairs was not lighted. The only lighted area was at the bottom of the stairs going into the childcare area.
The finding was discussed with the facility during the complaint investigation.
|
Plan of Correction
Program Director reviewed compliance issues as identified in P113 with the maintenance department on 11/6/2019.
Program Director will assure that additional light fixtures are installed in accordance with P113 (Childcare area) on 12/6/2019. |
705.11 (2) (ii) LICENSURE Child care.
705.11. Child care.
(2) Interior space. The residential facility shall:
(ii) Maintain security screens or safety locks for all operable windows.
|
Observations
During the physical plant tour, the facility failed to maintain security screen on all windows.
In room located on the second floor had two windows that was held open by books. The window also did not have security screens.
The finding was discussed with the facility during the complaint investigation.
|
Plan of Correction
Program Director met with the maintenance department on 11/6/2019 to follow-up on previous order for window screens. All windows were measured by outside vendor. Program Director will assure replacement screens are installed assuring compliance with P165 by 12/31/2019.
Program Director assured all books were removed from the window on 11/6/2019.
Program Director will review safety issues during weekly community meetings beginning 11/11/2019.
House managers will conduct hourly house runs to assure all windows are closed and secure while maintain compliance with P165 beginning 11/7/2019. |
705.11 (2) (iii) LICENSURE Child care.
705.11. Child care.
(2) Interior space. The residential facility shall:
(iii) Maintain protective caps over each electrical outlet.
|
Observations
During the physical plant tour on November 6, 2019, the facility failed to ensure that all electrical outlets have protective caps in the following rooms:
Group room
Client bathroom on the 1st floor
1st and 3rd floor hallways
Client Rooms; 9, 7, 8 and 9
The findings were discussed with the facility during the complaint investigation.
|
Plan of Correction
Program Director replaced socket covers in client bathroom on the 1st floor,
1st and 3rd floor hallways
Client Rooms; 9, 7, 8 and 9 on 11/6/2019.
Program Director reviewed safety issues with staff and residents during the community meeting on 11/18/2019 to assure all protective covers are replaced after utilizing the outlets.
Program Director implemented procedures to assure all electrical sockets are inspected for compliance and documented in the logbook. Director will assure compliance with P167 effective as of 11/18/2019.
House manager will conduct hourly house runs and assure electrical socket have protective caps in accordance with P167 effective and on-going as of 11/7/2019. |
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.
|
Observations
Based on review of a client's record and staff interviews during the investigation, the facility failed to ensure the client's confidentiality.
One client record was reviewed and during that review there was a faxed form dated 4/16/18 with the attachment of what was sent. There were two pages attached that had other client ' s names and identifying information including the client. Additionally, during the interviews with clients a administrative staff came in and mention the client ' s name in front of another client.
The findings were discussed with the facility during the complaint investigation.
|
Plan of Correction
Program director met with the administrator on 11/6/2019 to discuss process and procedures for protecting client information. Information not contained in the Electronic Health Records were immediately reviewed, stored and protected in accordance with regulations identified in (0276) on 11/6/2019.
program Director assured that documents in client record were removed and stored appropriately on 11/6/2019.
Program administrator will complete Confidentiality training by 1/6/2020.
Program Director will assure all on-going adherence with regulations identified in 0276 beginning 11/6/2019.
|
709.34 (c) (3) 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:
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence that results in the closure of a facility for more than 1 day.
|
Observations
Based on an interview with the Facility Director, the facility failed to notify the Department within 3 days of the incident.
The facility staff, women and children were temporarily moved to another location sometime in April for one day without notifying DDAP of this move.
The finding was discussed with the facility during the complaint investigation.
|
Plan of Correction
Program Director will assure that DDAP is notified 3 days prior to services rendered outside of the approved facility. Program Director will assure adherence with regulation 0361 effective beginning 11/6/2019. |
709.52(e)(2) LICENSURE Psychiatric supt serv
709.52. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(2) Psychiatric.
|
Observations
Based on the review of the facility's policy and procedures and interviews with clients, the facility failed to follow their procedure when it comes the time frame to see the psychiatrist.
The policy states that the psychiatrist will see the clients within 72 hours of admission, based on the interview this has not happened. Those clients saw the psychiatrist over a week or two after admission.
|
Plan of Correction
Program director and Nurse Manager will assure all residents are seen by the psychiatrist within 72 hours. All compliance issues will be documented and filed in Electronic Medical Records of the individual. All compliance issues will be immediately reported to the Program Director for further review. Program Director and Nurse Manager will assure compliance with regulations identified in 1779, effective 11/6/2019.
Nurse Manager will audit medical records 1x weekly and consult with the Psychiatrist to assure compliance with regulation 1779, effective 11/6/2019. |