INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 12, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gaudenzia, 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 personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee's #6 and #9 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 #6 was hired as a counselor on April 13, 2021 and was due to have the communicable disease trainings no later than April 13, 2022. 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 #9 was hired as a counselor on December 7, 2020 and was due to have the communicable disease trainings no later than December 7, 2021. There was no documentation in the personnel file of the completion of the HIV/AIDS training and TB/STD training as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The HIV/AIDS Trainings have been completed for both employees on 9/16/22.
TB/STD trainings will be completed for one of the two employees on 11/29/22 via the online DDAP training system.
The other staff member is currently on leave for the next 3 months. This employee will be scheduled to complete the training upon her return, no later than 1/31/23.
The Program Director and Division Director will complete Quarterly reviews of all employee training files to ensure that any employees requiring trainings will have them completed prior to the deadlines. This will be documented in a supervision note.
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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.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to keep the men's bathroom shower stalls clean, safe, sanitary and in good repair. The shower stalls were dirty and stained.
These findings were reviewed with facility staff during the inspection process.
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Plan of Correction
The bathroom has been cleaned professionally and will continue to be cleaned professionally on a monthly basis in addition to the daily cleaning done by the program.
This bathroom is part of a renovation project which is scheduled to begin in October of 2022 and is anticipated to last 3 months (to be completed by 1/31/23). The entire bathroom is being renovated.
A daily checklist will be utilized to ensure that the cleanliness of the bathroom is maintained. Any issues noted will be addressed immediately. The Program Director will review these checklists on a weekly basis and will document this review by initialing the checklists.
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705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
A review of the October 2021 through June 2022 fire drill logs was conducted during the onsite inspection. The facility failed to include whether there were problems encountered at the time of the drill during the 2021 months of October, November, December and the 2022 months of January, February, March, April, May, and June.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Fire Drill Grid has been updated to indicate whether any problems were encountered. The program will begin utilizing this revised grid in October 2022.
The Program Director will review the revised grid with program staff no later than 10/14/22. Each month the Program Director will review the grid to ensure that it has been completed correctly, and document this review by initialing the grid.
The Division Director will review the grid on a quarterly basis.
The Quality Assurance Department will conduct at least quarterly reviews of the program to include review of the Fire Drill Grid. Any issues noted will be brought to the attention of program management.
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