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 2, an abbreviated on-site inspection, conducted on November 16-20, 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 were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, Gaudenzia Erie, 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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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.
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Observations
Based on a physical site inspection on November 19, 2020, the facility failed to store all trash in covered containers. The dumpster lids were observed open.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Training will be completed with all staff regarding the need to maintain a safe and clean environment by ensuring all garbage, trash and rubbish is placed in the dumpster with the lid then being closed. The Program Director will complete the training.
House Managers will ensure the lid is closed by checking it on each shift.
House Manager Supervisor will be responsible to make sure the House Managers are shutting the lid.
Quality Assurance Manager will monitor for compliance during quarterly site visits.
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705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical site inspection on November 19, 2020, the facility failed to insecure hot water temperatures did not exceed 120F. The first floor ADA compliant bathroom temperature was 131.3F. The kitchen handwash station sink was 127.9F. The second-floor bathroom temperature was 134.3F. The third-floor bathroom temperature was 132.1F.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All water faucets will be checked for temperature weekly by the House Manager utilizing a water thermometer. The temperature will be documented on the Daily Checklist.
If the temperature is not within safety limits (not to exceed 120F), the House Manager will inform the Program Director immediately and the faucets will be marked out of order by signage as well as informing the clients not to use the water until it is deemed safe.
The hot water tank settings will be checked to make sure the settings have not been changed. If there is a problem in regulating the water temperature, the Program Director will contact the Operations Manager to address the problem immediately.
The water will not be used until the problem is identified, fixed and the temperature has been tested at all faucets to not exceed 120F.
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705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical site inspection on November 19, 2020, the facility failed to ensure fire extinguishers are inspected and approved annually. A fire extinguisher located on the third floor had a torn tag and therefore could not confirm it had been inspected on an annual basis.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The fire extinguisher will be checked each day by the House Manager to ensure it is properly secured and the inspection tag is legible and not torn. This will be documented on the Daily Checklist.
If the tag is torn or not legible, the Program Director will contact the company that completes the fire extinguisher inspections to report the problem and request a new tag. This will be documented in the Fire Drill Book. It will be the Program Director's responsibility to ensure the tag is replaced.
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705.11 (2) (iv) LICENSURE Child care.
705.11. Child care.
(2) Interior space. The residential facility shall:
(iv) Secure all hazardous and poisonous substances and materials with safety latches or locks.
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Observations
Based on a physical site inspection on November 19, 2020, the facility failed to secure all hazardous and poisonous substances with safety latches or locks. Cleaning disinfectants were observed on open shelving in the basement which is an area accessible to clients and their children.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All staff will be trained regarding the proper storage of hazardous and poisonous substances.
During the Daily Check, the House Manager will ensure all hazardous and poisonous substances are properly stored in the locked cabinet.
A locked storage cabinet has been purchased and placed in the basement where the disinfectants are located.
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709.28 (c) (2) 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. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of client records on November 16-20, 2020, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5(b) for releases of information in client record #'s 6 and 7. The release of information forms permitted progress notes to be released.
Client #6 was admitted on October 6, 2020 and was still active at the time of the inspection. The release of information form was dated October 6, 2020 to a government agency.
Client #7 was admitted on October 19, 2020 and was still active at the time of the inspection. The release of information form was dated on October 19, 2020 to a government agency.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Training will be completed with all staff regarding the correct way to complete a Consent to Release Information form. The Program Director will facilitate this training, stressing the 255.5 regulations regarding information being released to government agencies.
The Clinical Supervisor will review the releases while completing weekly chart audits and if any erroneous information is found, the Clinical Supervisor will address it with the staff member, new releases will be completed, and the old releases will be voided.
The Quality Assurance Manager will review releases during quarterly chart audits and report findings to the Program Director who will ensure that this is addressed as described above.
The Electronic Record System has been updated to allow only the items listed under the 255.5 regulations to be released to government agencies. When the staff member identifies the release is going to a government agency they will only be able to select items listed under the 255.5 regulations.
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