INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 31, 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 form, the facility failed to ensure that employees received the minimum of six hours of HIV/AIDS training and at least four hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #5 was hired as a counselor on September 21, 2020 and was due to have the communicable disease trainings no later than September 21, 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.
This finding was reviewed with facility staff during the licensing inspection.
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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 both employees on 11/29/22 via the online DDAP training system.
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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705.7 (b) (5) 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:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a physical plant inspection, the facility failed to maintain refrigerator temperatures according to the regulation. The facility's refrigerator located in the basement did not have a thermometer, therefore, the correct temperature could not be assessed.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The missing thermometer has been replaced at of 9/1/22.
A daily temperature log will be maintained to ensure the proper functioning of the refrigerator/freezer, as well as the presence and function of the thermometer. Any issues noted will be addressed immediately. The Program Director will review these logs on a weekly basis and will document this review by initialing the log.
The Quality Assurance Department will conduct at least quarterly reviews of the program to include review of the temperature logs. Any issues noted will be brought to the attention of program management.
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