INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted March 18-21, 2021 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Gaudenzia Kindred House was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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705.1 (3) LICENSURE Gen requirements for residential facilities.
705.1. General requirements for residential facilities.
The residential facility shall:
(3) Comply with applicable Federal, State and local laws and ordinances.
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Observations
Based on a physical plant inspection and staff and client interviews conducted during a complaint investigation May 18 -21, 2021, the facility failed to comply with federal, state and local laws.
Expired and moldy food is being provided to the clients. This was discussed with the facility staff during the complaint investigation.
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Plan of Correction
All expired food was discarded on 5/13/21. House Managers will check the expiration date and condition of all food at the time that it is brought into the facility and discard any food past its expiration date or which appears spoiled. House Manager Supervisor and/or Program Director will conduct spot checks on a weekly basis to ensure that these checks are happening as specified. In addition, the Quality Assurance Department conducts quarterly reviews, and the Compliance department conducts reviews of corrective action plans to ensure implementation.
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705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection conducted during a complaint investigation May 18 -21, 2021, the facility failed to maintain the exterior of the building in good repair.
Missing and torn window screens were observed in staff offices and client bedrooms. This was discussed with the facility staff during the complaint investigation.
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Plan of Correction
As of 6/22/21 the screens in question have replaced. Staff will monitor this and other hazards in hourly safety checks throughout the program which are documented on the run sheet. These are reviewed by the House Manager Supervisor and/or Program Director weekly to ensure that these are happening as scheduled and accurately documented. In addition the Quality Assurance Department conducts quarterly reviews, and the Compliance department conducts reviews of corrective action plans to ensure implementation.
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705.3 LICENSURE Living rooms and lounges.
705.3. Living rooms and lounges.
The residential facility shall contain at least one living room or lounge for the free and informal use of clients, their families and invited guests. The facility shall maintain furnishings in a state of good repair.
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Observations
Based on a physical plant inspection conducted during a complaint investigation May 18 -21, 2021, the facility failed to maintain furnishings in a state of good repair.
Torn couches and chairs were observed in the community room/client lounge. This was discussed with the facility staff during the complaint investigation.
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Plan of Correction
Replacement cushions/covers have been ordered for all furniture with tears. As soon as these arrive they will replace all torn cushions/covers. Staff will monitor the condition of the facility in monthly safety checks throughout the program. These are reviewed by the House Manager Supervisor and/or Program Director to ensure that these are happening as scheduled and accurately documented. Any identified as damaged will be repaired/replaced as appropriate. In addition the Quality Assurance Department conducts quarterly reviews, and the Compliance department conducts reviews of corrective action plans to ensure implementation.
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705.9 (1) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(1) Be free of rodent and insect infestation.
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Observations
Based on a physical plant inspection conducted during a complaint investigation May 18 -21, 2021, the facility failed to ensure that the facility was free from insects.
Dead termites were observed in the lower level of the facility. Over a dozen dead wasps were observed in the ceiling light covers in the client bedroom #6 and the adjoining bathroom. This was discussed with the facility staff during the complaint investigation.
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Plan of Correction
At the time of the visit, work had already begun on 4/16/21 to address this condition.
Currently, per the recent inspection by our operations Manager, there are no swarms and the bay stations are working.
The exterminator came to the facility to address the situation with the wasps on 4/21/21.
Staff will monitor the condition of the facility in hourly safety checks throughout the program which are documented on the run sheet. These are reviewed by the House Manager Supervisor and/or Program Director weekly to ensure that these are happening as scheduled and accurately documented. Any dead insects observed in the light fixtures will be cleaned out as needed. In addition the Quality Assurance Department conducts quarterly reviews, and the Compliance department conducts reviews of corrective action plans to ensure implementation.
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709.26 (a) (2) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(2) Rules of conduct.
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Observations
Based on a review of administrative documentation and client and staff interviews conducted during a complaint investigation May 18 -21, 2021, the facility failed to follow it's rules of conduct. A facility staff person had a personal relationship with a client. This violates the facility's Standards of Conduct Policy.
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Plan of Correction
As soon as management was made aware of this situation, a thorough internal investigation was conducted. Some portions of the allegation were substantiated and some were not. Report was given to DDAP reviewers during their onsite visit. Outcome: Client denied the relationship. Staff member has since resigned.
All staff members review and acknowledge the Standards of Conduct Policy and as part of the onboarding process. This was true for this staff member as well.
The topic of staff/client relationships was addressed in a staff meeting on 4/19/21 and the Standards of Conduct were reviewed at this time.
4/19/21 and ongoing
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709.34 (c) (5) 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:
(5) Outbreak of a contagious disease requiring CDC notification.
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Observations
Based on a physical plant inspection and staff and client interviews conducted during a complaint investigation May 18 -21, 2021, the facility failed to report an infectious condition.
The facility did not report the two staff and one client that tested positive for COVID-19 to the Department. This was discussed with the facility staff during the complaint investigation.
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Plan of Correction
Any "Outbreak of a contagious disease requiring CDC notification" will be documented and reported to DDAP within required timeframes. As of June 3, 2021, all incidents will be reviewed and discussed, including timely submission of reports, during weekly clinical team meetings. The Program Director will ensure that all reportable incidents will be submitted to DDAP within the regulatory timeframe.
All program staff are required to complete the Incident Management Refresher Course using the organization's online training system. The Program Director/Clinical Supervisor will ensure that all staff training will be completed as required and will ensure that all incidents reports are completed and submitted according to regulatory guidelines. Findings will also be reported and documented in the monthly Eastern Region CQI Meetings. In addition the Quality Assurance Department conducts quarterly reviews, and the Compliance department conducts reviews of corrective action plans to ensure implementation.
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709.52(d) LICENSURE Regularity of counseling provided
709.52. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
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Observations
Based on staff and client interviews conducted during a complaint investigation May 18 -21, 2021, the facility failed to ensure that counseling is provided to clients on a regular and scheduled basis.
One of the facility's counselors continuously falls asleep while facilitating group and individual counseling sessions. This was discussed with the facility staff during the complaint investigation.
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Plan of Correction
As soon as management became aware of this situation, it was addressed directly with this staff member in supervision with the Division Director and the Program Director on 5/26/21. This will be addressed more generally in a staff meeting on 6/25/21 reminding staff members that if they are experiencing anything which might have an effect on their work performance that they should bring it to their supervisor's attention so that a plan can be formulated to ensure the health and safety of staff and clients. The Program Director will continue to observe staff members in the performance of their duties and address any such issues as they arise.
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