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 5, 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 Inc. Fountain Springs 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 (1) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
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Observations
Based on a physical plant inspection, the facility failed to ensure that all playground equipment was free from any danger to health or safety as evidenced by the swings that had broken chains and wrapped/hung around the frame of the swing set. These chains were still accessible to the children and could become dangerous to children ' s safety.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Program Director and staff removed the swings and chains from the swing set immediately following the licensing visit. Replacements were ordered.
The Program Director and assigned Staff representative will monitor ongoing swing set safety and report via the monthly safety committee report.
Resolution Date: 11-6-20 |
709.53(a)(11) LICENSURE Follow-up information
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to ensure documentation of follow up information in three of three applicable client records.
Client#5 was admitted on January 17, 2020 and discharged on July 10, 2020.
Client #6 was admitted on May 18, 2020 and discharged on October 13, 2020.
Client #7 was admitted on November 26, 2019 and discharged on May 19,2020.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The program's clinical staff will assure documentation of follow up post client discharge in all applicable records in conformance with licensing regulations.
A new Follow Up form was added to the electronic healthcare record and reviewed with staff by the Clinical Supervisor.
Ongoing conformance will be monitored via monthly record audits performed by the Clinical Supervisor and the Continuous Quality Improvement Department.
Resolution Date: 11/13/20 |