INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 15, 2023, 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. Winner Co-Occurring Women and Children Program 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)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of staff schedules and CPR certifications provided by the facility, the facility failed to ensure that at least one person certified in CPR was onsite during the project's hours of operations. The following shifts did not have staff certified in CPR:
May 7, 2023 from 11:00 p.m. - 7:00 a.m.
May 16, 2023 from 05:00 p.m. - 7:00 p.m.
May 20, 2023 from 7:00 a.m. - 3:00 p.m.
May 21, 2023 from 11:00 p.m. - 7:00 a.m.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of June 16, 2023, the staff schedule had at least one person certified in CPR onsite during the project's hours of operation.
The following plans are in place to prevent reoccurrence:
a. As of June 16, 2023, the program director or assigned staff will conduct biweekly reviews of staff trainings to ensure that at least one staff on shift is CPR certified.
b. The administrative coordinator will provide monthly training reports to submit to the program director or assigned staff
c. The Division Director and CQI Department will review training grids that include CPR trainings at least monthly. Findings will be immediately reported to program management and documented in audit reports.
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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 on June 15, 2023, the facility failed to ensure that garbage was stored in covered containers that prevent the penetration of insects and rodents as there were three uncovered dumpsters in the rear of the building.
This is a repeat citation from the May 24, 2022 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of June 15, 2023, the dumpster was emptied and covered. The following plans has been put place to address the uncovered dumpsters:
a) The dumpsters will be monitored daily by Residential Support Professionals. This will be documented on the Facility Run Sheets.
b) The program director or assigned staff will conduct at least weekly inspections.
c) The Division Director and CQI Department will conduct at least monthly inspections. Findings will be immediately reported to program management and documented in audit reports. |
705.5 (b) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(b) Each shared bedroom shall have at least 60 square feet of floor space per resident measured wall to wall, including space occupied by furniture. When bunk beds are used, each bedroom shall have at least 50 square feet of floor space per resident measured wall to wall. Bunk beds shall afford enough space in between each bed and the ceiling to allow a resident to sit up in bed. Bunk beds shall be equipped with a securely attached ladder capable of supporting a resident. Bunk beds shall be equipped with securely attached railings on each open side and open end of the bunk. The use of bunk beds shall be prohibited in detoxification programs. Each single bedroom shall have at least 70 square feet of floor space per resident measured wall to wall, including space occupied by furniture.
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Observations
Based on a physical plant inspection on June 15, 2023, the facility failed to ensure that bunk beds were equipped with securely attached railings as the bunk bed in Bedroom #12 did not have a railing.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of July 7, 2023, the bunk bed in Bedroom #12 has been equipped with a securely attached railing.
The residential support professionals will conduct a daily facility inspection that will include ensuring all bunk bed railings are securely attached. The program director or assigned staff will conduct at least weekly inspections to ensure bunk bed railings are securely attached.
The division director and CQI Department will conduct and document monthly inspections. Findings will be immediately reported to program management and documented in audit reports.
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705.7 (b) (6) 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:
(6) Store all food items off the floor.
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Observations
Based on a physical plant inspection on June 15, 2023, the facility failed to store all food items off the floor as a box of hot chocolate was found on the floor of the second floor food storage closet.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of June 15, 2023, the box of hot chocolate was placed back on the shelf in the food storage closet.
Going forward, the residential support professionals will conduct a daily facility inspection that will include the food storage closet. The program director or assigned staff will conduct at least weekly inspections to ensure all food items are stored off the floor.
The division director and CQI Department will conduct and document monthly inspections. Findings will be immediately reported to program management and documented in audit reports.
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705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection on June 15, 2023, the facility failed to ensure that heaters were permanently mounted as a space heater was found in the staff office in the basement childcare area.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of June 15, 2023, the heater was removed from the staff office.
Going forward, the residential support professionals will conduct a daily facility inspection that will include space heaters. The program director or assigned staff will conduct at least weekly inspections to ensure that space heaters are not present and heaters are permanently mounted.
The division director and CQI Department will conduct and document monthly inspections. Findings will be immediately reported to program management and documented in audit reports.
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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of seven client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients in two of two applicable records reviewed.
Client # 2 was admitted on September 9, 2022 and was discharged Against Staff Advice (ASA) on December 16, 2022. The facility failed to follow their policy related to ASA discharges of calling the Emergency Contact within twelve hours.
Client # 4 was admitted on November 23, 2022 and was discharged Against Staff Advice (ASA) on April 10, 2023. The facility failed to follow their policy related to ASA discharges of calling the Emergency Contact within twelve hours.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
As of June 16, 2023, the program director conducted an in-service refresher training with the staff responsible for following up on ASA discharges.
The following plans are in place to prevent reoccurrence:
d. The clinical supervisor will conduct a weekly audit to include ASA discharge follow-up.
e. The program director or assigned staff will conduct at least weekly audits.
f. The Division Director and CQI Department will conduct at least monthly inspections. Findings will be immediately reported to program management and documented in audit reports.
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709.28 (c) 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.
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Observations
Based on a review of seven client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in one record reviewed.
Client # 7 was admitted on April 19, 2023 and was active at the time of the inspection. The consent to release information form to the funding source was not signed until June 8, 2023, and there was evidence of billing prior to the client signed consent to release information form.
This is a repeat citation from the May 24, 2022 and June 10, 2021 annual licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of July 17, 2023, the program director conducted an in-service refresher training with the staff responsible for obtaining client's consent to release information.
The following plans are in place to prevent reoccurrence:
a. The clinical supervisor will conduct a weekly audit to include client's consents.
b. The program director or assigned staff will conduct at least weekly audits.
c. The Division Director and CQI Department will conduct at least monthly inspections. Findings will be immediately reported to program management and documented in audit reports.
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709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of seven client records, the facility failed to ensure that consent to release information forms included the name, agency or organization to whom disclosure is made in one record reviewed.
Client #4 was admitted on November 23, 2022 and discharged on April 10, 2023. The record contained a consent to release information form signed by the client on March 3, 2023 that was missing the name, agency, or organization to whom disclosure was to be made.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of July 17, 2023, the program director conducted an in-service refresher training with the staff responsible for documenting client's consents to release information. The refresher training included training on including the name, organization, or agency on consent to release information forms.
The following plans are in place to prevent reoccurrence:
a. The clinical supervisor will conduct a weekly audit to include consents to release information.
b. The program director or assigned staff will conduct at least weekly audits.
c. The Division Director and CQI Department will conduct at least monthly inspections. Findings will be immediately reported to program management and documented in audit reports.
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709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records and the facility's policies and procedures, the facility failed to document a psychosocial evaluation, within 72 hours of admission, in three of seven applicable records reviewed.
Client # 1 was admitted on August 18, 2022 and was discharged on October 30, 2022. The record did not contain a psychosocial evaluation.
Client # 3 was admitted on May 25, 2022 and discharged on January 31, 2023. The psychosocial evaluation was not completed until August 13, 2022.
Client # 5 was admitted on December 29, 2022 and was active at the time of the inspection. The psychosocial evaluation was not completed until January 11, 2023.
These finding were discussed with facility staff during the licensing process.
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Plan of Correction
As of July 17, 2023, the program director conducted an in-service refresher training with the staff responsible for documenting the psychosocial evaluation.
The following plans are in place to prevent reoccurrence:
a. The clinical supervisor will conduct a weekly audit to include psychosocial evaluation timeframe.
b. The program director or assigned staff will conduct at least bi-weekly audits.
c. The Division Director and CQI Department will conduct at least monthly inspections. Findings will be immediately reported to program management and documented in audit reports.
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709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records and a physical plant inspection, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for obtaining client signed consent to release information forms prior to disclosures of information was submitted and approved by the Department for the May 24, 2022 and June 10, 2021 annual licensing inspections. Obtaining client signed consent to release information forms prior to disclosing information was again found to be a deficiency in the June 15, 2023, licensing inspection.
A plan of correction for ensuring that garbage was stored in covered containers that prevent the penetration of insects and rodents was submitted and approved by the Department for the May 24, 2022 annual licensing inspection. Covering garbage containers was again found to be a deficiency in the June 15, 2023 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director has responsibility to ensure that Plan of Corrections (POC) are implemented.
To prevent repeated citations in the client records, additional staff training and weekly chart audits will be performed by the clinical supervisor.
To prevent repeated physical plant citations, staff will complete daily monitoring sheets that include checking areas of previous citations.
The Program Director and CQI Department Manager will oversee monitoring steps to prevent repeated citations.
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