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 6, 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- New Desinty 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 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on a physical plant inspection the facility failed to ensure that all trash was stored in a covered container as evidenced by the facility ' s dumpster lid kept open.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Program Director will ensure compliance to regulation 705.2 by posting a sign that states the dumpster lid is to be closed at all times. Program Director held a mandatory staff meeting on 11/12/2020 to discuss the proper maintenance of the trash dumpsters. In addition, the trash dumpster area will be added to both the client and staff house run sheet, daily, to ensure that the area is secure. A supervisory note will be placed in each personnel file documenting awareness and understanding of the regulation. House run sheets will be reviewed weekly by Clinical Supervisor. Additionally, the Regional Quality Assurance manager will conduct quarterly site visits to ensure compliance; this visit will be documented in the quarterly CQI report. |
705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a physical plant inspection, the facility failed to ensure that all cold food was kept at or below 40F and frozen food below 0F as no thermometers were within the refrigerators to verify temperature. In addition, the facility did not have a temperature log for each of the five refrigerators kept in the facility directors suite.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
As of 11/24/2020, all refrigerators and freezers utilized by residents are equipped with a thermometer to ensure all food is kept within the required temperatures for refrigerated and frozen foods, in order to be in compliance with regulation 705.7. In addition, Program Director and staff will track temperatures through the use of individual temperature tracking logs, located on each refrigerator. Program Director will review for compliance during monthly, internal CQI process. The Regional Quality Assurance Manager will conduct quarterly site visits to ensure compliance. |
705.29 (2) (iii) LICENSURE Child care.
705.29. Child care.
When a nonresidential facility admits children for services or for custodial care, the following requirements apply:
(2) Interior space. The nonresidential facility shall:
(iii) Maintain protective caps over each electrical outlet.
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Observations
Based on a physical plant inspection, the facility failed to ensure that all electrical outlets maintained a protective cap over each outlet as evidenced by the appliance outlet that was not covered and could be accessed by children.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Program Director and Childcare worker ensure protective caps over all electrical outlets. Exposed outlet was covered with a screwed-in plate cover, on 11/6/2020, while DDAP inspector was on site. In order to keep in compliance with regulation 705.29,inspection of all outlet covers is added to house run list conducted by staff. Program director will review completed house run sheets monthly. Additionally, the Regional Quality Assurance Manager will conduct quarterly site visits to ensure compliance and will be documented in the quarterly CQI report. |
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 seven client records, the facility failed to keep all releases for all seven records for the funding sources within the limits of 255.5. These releases all included the release of Mental Health Records, Medication Records, Assessments and Physical/Medical records.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Program Director conducted a training with Clinical Staff and Administrative Assistant on 11/12/2020 on the 5-points of consents and releases in order to be in compliance with regulation 709.28. Supervisory notes were placed in personnel file documenting awareness and understanding of the regulation. Compliance to this confidentiality regulation will be ensured by Program Director and Clinical Supervisor during monthly internal CQI process. Additionally, the Regional Quality Assurance Manager will conduct quarterly audits to ensure compliance. This audit will be documented in the quarterly CQI report. |
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of seven client records, the facility failed to ensure that all work done by clients within the facility is an is an integral part of his treatment and rehabilitation plan in all seven client records.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
On 11/12/2020, Program Director and Clinical Supervisor reviewed with all Clinicians, regulation 709.53, requiring all work performed within the facility, by residents, to be included in the individual treatment plan as a therapeutic tool for improvement of daily living skills. The Clinical Supervisor will monitor compliance through regular approval of all treatment plans and monthly CQI internal audits. A supervisory note will be placed in each personnel file documenting awareness and understanding of the regulation. Additionally, the Regional Quality Assurance Manager will conduct quarterly audits to ensure compliance. This audit will be documented in the quarterly CQI report. |