INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site, at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 1, an abbreviated off-site inspection, conducted on May 29, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.
Based on the findings of Part 1, an abbreviated off-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 the review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee #5 received at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #5 was hired as a counselor on November 25, 2018 and was due to have the communicable disease trainings no later than November 25, 2019. There was no documentation provided of the completion of the TB/STD training as of the date of the licensing inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
All staff persons and volunteers will 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 will complete the training within the first year of employment. The Program Director will maintain a training log of all staff that will be reviewed on a quarterly basis to ensure compliance.
Employee #5 will complete the required TB/STD training by 07/01/2020, The Clinical Director will review required training with the staff members during regular supervision. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of the personnel records, the facility failed to document that staff was instructed in the use of the fire extinguisher upon staff employment in three of four personnel records reviewed.
Employee #2 was hired on January 27, 2020 and was a current employee at the time of the inspection. There was no documentation that this employee received instruction on the use of the fire extinguisher upon employment.
Employee #3 was hired on December 23, 2019 and was a current employee at the time of the inspection. There was no documentation that this employee received instruction on the use of the fire extinguisher upon employment.
Employee #4 was hired on February 3, 2020 and was a current employee at the time of the inspection. There was no documentation that this employee received instruction on the use of the fire extinguisher upon employment.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Within 7 days of hire, all employees will complete the fire extinguisher/emergency procedures training as part of the new employee orientation training.
The Program Director will maintain a training log and ensure that all employees are scheduled for this mandatory training within 7 days of hire.
Employees #2, #3 and #4 will all complete the required training by 07/01/2020. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on the review of the May 2019 through May 2020 fire drill logs, it was determined that the facility had failed to conduct a fire drill during sleeping hours at least once every six months.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Fire drills will be conducted during sleeping hours at least every six months.
As of 06/12/20 the Program Director will review the fire drill logs on a monthly basis to ensure that all drills are completed. |