INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 8, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Broad Street 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)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on the review of personnel records, staff schedules and the Staffing Requirement Facility Summary Report, the project failed to provide to a sufficient number of staff persons with a CPR certification and first aid training onsite during the project's hours of operation.For the month of May 2021, staff members who worked between the hours of 8:00pm and 8:00am, Mondays through Fridays, did not have a documented CPR/First Aid certification. Additionally, for the month of May 2021, staff members who worked anytime on Saturdays and Sundays from 12am to 12pm and 4:00pm to 11:59pm did not have a documented CPR/First Aid certification. These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Program Director has completed a thorough review of all staff training requirements and all staff in need of CPR/First Aid training completed re-certification on 06/07/2021.
In addition, the Program Director has amended the schedule to ensure that staff with CPR/First Aid training are available on all shifts.
The Program Director will also review training requirements on a monthly basis to ensure that all staff trainings are up to date.
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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 the physical plant inspection, the facility failed to ensure that the hot water temperature did not exceed 120 degrees Fahrenheit.When tested, the water in the second-floor staff bathroom was 138.7 degrees Fahrenheit.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from last year's licensure renewal inspection.
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Plan of Correction
The maintenance department has adjusted the water temperature to less than 120F.
In an effort to ensure continuous compliance the maintenance staff will check the hot water temperature on a weekly basis to ensure that the temperature of the hot water does not exceed 120F.
In addition, the water temperature will be monitored by the CQI Department during quarterly CQI site inspections and findings will be reported to the Program Director.
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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, the project failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in three of seven client records reviewed.Client #1 was admitted on November 12, 2020 and was discharged on January 26, 2021. A release of information form to the funding source, signed and dated by the client on November 13, 2020, allowed for the release of psychological/psychiatric evaluations, treatment plans, case consultations, assessments, progress notes, mental health records, discharge summary and medical records, all of which exceeds the limits established by 4 Pa. Code 255.5.Client #2 was admitted on January 29, 2021 and was an active client at the time of the inspection. A release of information form to a government agency, signed and dated by the client on March 12, 2021, allowed for the release of psychological/psychiatric evaluations, treatment plans, case consultations, assessments, progress notes, mental health records, discharge summary and medical records, all of which exceeds the limits established by 4 Pa. Code 255.5.Client #4 was admitted on December 30, 2020 and was discharged on May 18, 2021. A release of information form to a government agency, signed and dated by the client on March 12, 2021, allowed for the release of psychological/psychiatric evaluations, treatment plans, case consultations, assessments, progress notes, mental health records, discharge summary and medical records, all of which exceeds the limits established by 4 Pa. Code 255.5.These findings were reviewed with project staff during the licensing process.This is a repeat citation from last year's licensure renewal inspection.
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Plan of Correction
The Program Director will review Confidentiality and Releases of Information with all staff during staff in-service on 07/15/2021.
In addition, the Program Director and Clinical Supervisor will monitor confidential releases of information during monthly file audits and address discrepancies during staff supervisions.
The CQI department will monitor confidentiality and releases of information during quarterly CQI file audits and will report findings to the Program Director.
The release of information for Client #2 dated March 12, 2021 has been "revoked" and a new consent has been completed for the funding source that is within the required scope. All other clients have been discharged.
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709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the purpose of disclosure in one of seven client records reviewed.Client #5 was admitted on April 2, 2021 and was a current client at the time of the inspection. A release of information form for a probation agency, signed and dated by the client on April 5, 2021, did not document the purpose of disclosure.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Program Director will review Confidentiality and Releases of Information with all staff during staff in-service on 7/15/2021
In addition, the Program Director and Clinical Supervisor will monitor confidential releases of information during monthly file audits and address discrepancies during staff supervisions.
The CQI department will monitor confidentiality and releases of information during quarterly CQI file audits and will report findings to the Program Director. The release of information for Client #5 dated April 2, 2021 has been "revoked" and a new consent has been completed for probation that includes the purpose of the disclosure. All other clients have been discharged.
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709.34 (c) (1) 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:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on the review of the unusual incident log, the project failed to file a written unusual incident report with the Department within three business days following an unusual incident involving a physical or sexual assault by staff or a client.On December 7, 2020, there was documentation of a physical assault that occurred between clients. A written unusual incident report was not filed with the Department.These findings were reviewed with project staff during the licensing process.This is a repeat citation from last year's licensure renewal inspection.
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Plan of Correction
The Program Director has reviewed and forwarded all unusual incident reports noted.
The Program Director will review the incident log on a weekly basis to ensure that all reports are sent to the Department within 3 days. In addition, on a quarterly basis the CQI Department will review the incident log to ensure compliance and report findings to the Program Director.
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709.34 (c) (4) 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:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on the review of the unusual incident log, the project failed to file a written unusual incident report with the Department within three business days following an unusual incident involving an event at the facility requiring the presence of police, fire or ambulance personnel.On November 28, 2020, law enforcement was contacted and presented at the facility. A written unusual incident report was not filed with the Department.On December 7, 2020, law enforcement was contacted and presented at the facility. A written unusual incident report was not filed with the Department.These findings were reviewed with project staff during the licensing process.This is a repeat citation from last year's licensure renewal inspection.
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Plan of Correction
The Program Director has reviewed and forwarded all unusual incident reports noted.
The Program Director will review the incident log on a weekly basis to ensure that all reports are sent to the Department within 3 days. In addition, on a quarterly basis the CQI Department will review the incident log to ensure compliance and will report findings to the Program Director for follow up.
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709.54(a)(2) LICENSURE Receiving/storing/preserving
709.54. Project management services.
(a) An inpatient nonhospital project shall have written policies and procedures for its dietetic services which include, but are not limited to:
(2) Receiving, storing and preserving of food stuff.
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Observations
Based on a physical plant inspection, the facility failed to follow policies and procedures for its dietetic services which include, but are not limited to receiving, storing and preserving of food stuff.Moldy oranges were found on a shelf in the food preparation area.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The oranges were immediately removed and discarded. On a daily basis the Food Service Personnel will inspect the refrigerator and food service area to ensure that all items are stored properly and that expired or spoiled items are removed.
The Program Director will review proper food storage with the Food Service personnel on 07/08/2021.
In addition, the CQI department will inspect the site on a quarterly basis, to include the kitchen and food storage areas, and will share findings with the Program Director for follow up.
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