INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted February 17-18, 2022, 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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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 a review of the unusual incident reports for December 2021 through February 17, 2022, the facility failed to report a claim of physical or sexual assault by staff to the Department within 3 business days.
A report dated February 8, 2022 for alleged physical assault was submitted to DDAP on February 17, 2022.
This was reviewed with the facility during the investigation.
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Plan of Correction
All significant incidents will be reported to and reviewed daily by the Program Director or their designee. The Program Director/Clinical Supervisor will ensure that all incident reports are completed and signed within 24 hours and submitted to DDAP as required by standard 709.34(c)(1). The Program Director or designee will also inform the Women & Children's Division Director of all DDAP-reportable incidents within 24 hours of the incident. In addition, all incidents will be uploaded to Gaudenzia's Internal Incident Portal System.
All new program staff will be required to complete an Incident Management Refresher Course using the organization's online training system. The Program Director/ Clinical Supervisor will ensure all current staff have completed, or will complete this training by March 31, 2022. In addition, the Quality Assurance Department will conduct quarterly reviews and the Compliance Department will conduct annual reviews of corrective action plans to ensure implementation.
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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 a review of unusual incident reports from December 2021 through February 17, 2022, the facility failed to report the presence of ambulance personnel to the Department within 3 business days.
Two incident reports involving ambulance personnel on the premises were not submitted to DDAP. The first occurrence was on January 19, 2022 and the second was February 5, 2022.
These were reviewed with facility staff during the investigation.
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Plan of Correction
All significant incidents will be reported and reviewed daily by the Program Director or their designee. The Program Director/Clinical Supervisor will ensure that all incident reports are completed and signed within 24 hours and submitted to DDAP as required by standard 709.34(c)(4) The Program Director or designee will also inform the Women & Children's Division Director of all DDAP-reportable incidents within 24 hours of the incident. In addition, all incidents will be uploaded to Gaudenzia's Internal Incident Portal System.
All new program staff will be required to complete an Incident Management Refresher Course using the organization's online training system. The Program Director/ Clinical Supervisor will ensure all current staff have completed, or will complete this training by March 31, 2022. In addition, the Quality Assurance Department will conduct quarterly reviews and the Compliance Department will conduct annual reviews of corrective action plans to ensure implementation.
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