INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 9, 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 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of three personnel records, the facility failed to ensure that staff received at least 6 hours of HIV/AIDS training within two years in one record reviewed.
Employee # 1 was hired by the facility on September 9, 2019 as the Project Director and has remained in the same position. The employee was due to have the HIV/AIDS training no later than September 9, 2021; however, it was not completed until September 30, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff will complete all required training within required timeframes, as delineated in 704.11.
Going forward, the Training department will monitor the training requirements of the Project Director to ensure completion of all required trainings prior to deadlines.
These will be completed using a combination of internally-available trainings developed in collaboration with DDAP, and external trainings provided via BHTEN or other DDAP-approved resources.
The Quality Assurance department will conduct a review of all Plans of Correction within 9 months to ensure full implementation.
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705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of three personnel records, the facility failed to ensure that each staff was instructed in the use of the fire extinguishers upon employment in two records reviewed.
Employee #2 was hired as the facility director on July 19, 2021 and was due to be trained in the use of fire extinguishers by July 26, 2021; however, fire safety training was not documented as complete until December 7, 2021.
Employee #3 was hired as a house manager on October 12, 2021 and was due to be trained in the use of fire extinguishers by October 19, 2021; however, fire safety training was not documented as complete until December 7, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff will complete all required Fire Safety and Fire Extinguisher training within required timeframes, as delineated in 705.10. The Program Director will ensure that all staff complete these trainings upon employment. These will be conducted by the Program Director with each employee as part of the orientation process on-site. This will be documented in the employees file. The Quality Assurance department will conduct a review of all Plans of Correction within 9 months to ensure full implementation. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a physical plant inspection and documentation provided by the facility, the facility failed to conduct unannounced fire drills at least once a month, as no fire drills were conducted between May 2021 through November 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The program will conduct a Fire drill at least once a month. These drills will be documented on the Fire Drill Log. A Fire Drill was conducted on December 7, 2021. The Program Director and Division Director will review the Fire Drill Log each month to ensure that all are conducted according to DDAP 705.10 d 1 standards. The Quality Assurance department will conduct at least quarterly reviews to include physical plant inspections and reviews of the Fire Drill Log, the findings of which will be discussed with the program, and action steps developed. The Quality Assurance department will conduct a review of all Plans of Correction within 9 months to ensure full implementation. |