INITIAL COMMENTS
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This report is a result of an on-site follow-up inspection to the initial on-site licensure inspection conducted on June 2, 2010 by staff from the Division of Drug and Alcohol Program Licensure.
The follow-up inspection was conducted on March 4, 2011 by staff from the Division of Drug and Alcohol Program Licensure.
Based on the findings of the onsite follow-up 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 and a plan of correction is due on May 18, 2011.
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Plan of Correction
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704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
This deficiency can not be re-evaluated until the next licensing inspection.
The facility did not have training feedback forms on-site that could be reviewed at the time of the follow-up inspection that was conducted on March 4, 2011.
Please resubmit the original plan of correction date for the date of completion.
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Plan of Correction
Original plan from 6/2/10 stated, "Program Director and Administrative Coordinator will keep calendar of staff trainings and insure filing of staff training evaluations by month's end. Personnel charts will be reviewed by Program Director each quarter to insure compliance." |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based upon observation, a physical plant inspection, and an interview with the clinical supervisor, the facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
The findings include:
A physical plant inspection was conducted on March 4, 2011 between approximately 9:30 AM and 11:30 AM and another physical plant inspection between 3:00 PM and 3:30 PM.
It was observed that the yard/children's play area had four drain pipes lying on the ground.
The clinical supervisor confirmed that the pipes were lying in the children's play area, but she was not sure what they were or why they were lying there.
The facility had four uncovered garbage cans and two large dumpsters located in the children's exterior play area.
There was a utility cart left in the children's play area.
There was a 4" x 4" x 8' piece of treated lumber that was standing on end and unsecured, along with leaves, trash and other debris located at the bottom of the stairs that serve as the second exit from the basement. This exit also serves as the access from the children's inside play area to the exterior play area.
Bedroom # 1 on the first floor was observed to have stained/water damaged ceiling tiles, torn window shades, and a soiled carpet.
The shower drain in the bathroom of bedroom#1 did not have a cover on it and a child as well as an adult could get a hand stuck/injured if they were to put their hand in the drain. A child's toy was in the shower, right next to the open drain.
There were articles of clothing and toys piled on the beds, under the beds, and on the floor in cardboard boxes. The mattress cover on the bed near the window was dirty.
Bedroom # 2 was observed to have stained ceiling tiles and a soiled carpet.
Bedroom # 3 had a foul odor, and was observed with an overflowing trash can. The occupant of bedroom # 3 was interviewed at which time she confirmed that her bed as well as the beds of her three children were not issued mattress covers and pillow covers so as to keep the bed mattress and pillows clean, safe, in good repair, and deter bedbugs.
Bedroom # 4 was observed with a hole in the wall behind the door, a soiled carpet, it was cluttered and lacked cleanliness.
Bedrooms # 0, 6, 8, 11, and 12 were observed to have soiled carpets.
Bedroom # 7 was observed to have a soiled carpet and torn window blinds.
The ADA bathroom located on the first floor had a missing ceiling tile which revealed exposed and cracked dry wall, damp wooden joists and sub-flooring above and unsecured electrical wiring, fire alarm wiring and an unsecured electrical junction box.
The clinical supervisor confirmed that there was a hole in the bathroom ceiling.
The girls restroom on the 2nd floor (next to kitchen) had a torn window shade.
The carpet in the counselors' office was soiled.
The clinical supervisor confirmed the observations.
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Plan of Correction
Some issues were due to construction being done on Tioga Arms next door to Winner. Drain pipes have been removed. Open trash cans have been removed. Utility cart has been removed from the play area. The dumpsters will remain covered with lids down. Lumber that was in bottom of stair well has been removed.
Maintenance requests have been submitted to Gaudenzia Maintenance system for ceiling tiles and soiled carpet; drain cover for shower stall,and ladders attached to the bunk beds. Any holes in the dry wall will be spackled.
Projected date of completion for the work is May 27, 2011.
House managers will do house runs daily to get trash out of bedrooms from the night before and will have women tidy the rooms on a daily basis. This has beenn implemented as of may 1, 2011.
Bedroom 3 had mattress covers and pillow covers as of 4/28/2011
The Program Director will have a checklist for physical plant issues that will be reported on monthly to the Division Director. Monthly walk throughs with building maintanance will be documented on the checklist.
responsibility for compliance is the Program Director's.
The Division Director has a meeting with the CFO on Friday, June 17 to discuss the replacement of carpets. This meeting will give the Director and idea as to when the work will be completed. This completon date will be updated in the response to the June 1 inspection.
Ceiling tiles are being replaced and work will be completed by June 27, 2011.
All other work cited as being done, ladders, shower drain, and the work in the ADA room was done within timeframes originally given.
As of 7/11/2011, Director has been given a projected date of 8/31/2011 as the time frame for getting carpets replaced. |
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 upon observation, a physical plant inspection, and an interview with the clinical supervisor, the facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard were not free of hazards.
The findings include:
A physical plant inspection was conducted on March 4, 2011 between approximately 9:30 AM and 11:30 AM and another physical plant inspection between 3:00 PM and 3:30 PM.
It was observed that the yard/children's play area had four uncovered garbage cans and two large dumpsters, with lids in th open position and pushed against the fence such that they could not be closed.
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Plan of Correction
POC is the same as P009 - same issue was cited in P009 and the POC is the same |
705.5 (a) (3) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(a) In each residential facility bedroom, each resident shall have the following:
(3) A storage area for clothing.
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Observations
Based upon observation and a physical plant inspection, the facility failed to provide a storage area for clothing for all residents in bedrooms # 0, 1, 3, 4, and 8.
The findings include:
A physical plant inspection was conducted on March 4, 2011 at approximately 9:30 AM and 11:30 AM and another physical plant inspection between 3:00 PM and 3:30 PM.
Bedroom # 0 lacked sufficient storage for clothing. Clothing was piled on bunk beds, on top of dressers, and on the floor.
Bedroom # 1 lacked sufficient storage for clothing. Clothing was stored on the two beds, on top of dressers, and on the floor.
Bedroom # 3 lacked sufficient storage for clothing. Clothing was stored in plastic storage containers, laundry bags, plastic bags, piled on the bunk bed and on top of dressers.
Bedroom # 4 lacked sufficient storage for clothing. Clothing was piled on bunk beds, on top of dressers, and on the floor.
Bedroom # 8 lacked sufficient storage for clothing. Clothing was stored in plastic bags, on top of dressers, and on the floor.
The clinical supervisor stated that the bedrooms needed to be cleaned up.
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Plan of Correction
The facility recommends that each woman bring a week's worth of clothing for herself and two weeks for her children. Counselors, as part of the woman's adult daily livin skills work is to tour the room with their clients and remove excess clothing that can either be sent to relative's houses or placed into storage, or contributed to a clothing drop. All rooms will be inspected by the Staff on Duty on Saturdays. This was implemented as of May 1, 2011. |
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 upon observation, a physical plant inspection, and an interview with the clinical supervisor, the facility failed to provide a securely attached ladder and/or securely attached railing each open side and open end of the bunk for the bunk beds in bedrooms # 0, 3, 4, 7, 8, 9, and 11.
The findings include:
A physical plant inspection was conducted on March 4, 2011 at approximately 9:30 AM and 11:30 AM and another physical plant inspection between 3:00 PM and 3:30 PM.
Bedroom # 0 had two sets of bunk beds; the ladder for the bunk beds was not securely attached to the beds; one ladder was on a wall in the corner. In addition, one of the top bunks was missing a securely attached railing on the open side of the bunk.
Bedroom # 3 was observed with a bunk bed without a securely attached ladder.
Bedroom # 4 was observed with a bunk bed without a securely attached ladder.
Bedroom #7 had two sets of bunk beds; the ladder for the bunk beds was not securely attached to the beds.
Bedroom # 8 and 9 was observed with bunk beds without a securely attached ladder.
Bedroom # 11 was unoccupied at the time of the inspection; however, a bunk bed was observed in the room without a securely attached ladder.
The clinical supervisor confirmed that the bunk beds did not have ladders.
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Plan of Correction
Maitenance request has been submitted to have ladders securely placed on all bunk beds. At the Winner program, each woman has her own room and often the top bunks are not used. However to meet compliance we will have ladders attached. Projected date of completion for this is May 23, 2011.
Monthly physical plant inspections will be done by the Program Director and building maitenance. A inspection checklist will be utilized for identifying the problem and completion date of any issue. |
705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based upon observation and a physical plant inspection, the facility failed to provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom. In addition, the facility failed to provide residents with individual bars of soap (with labeled soap container) and a personal towel.
The findings include:
A physical plant inspection was conducted on March 4, 2011 at approximately 9:30 AM and 11:30 AM and another physical plant inspection between 3:00 PM and 3:30 PM.
The girls' restrooms (3 restrooms) on the second floor were observed with individual bars of soap in the bathtub and wash cloths hanging on the bathtub and sink. Also, one of the restrooms did not have paper towels or a mechanical dryer.
The boys restroom on the third floor was observed with individual bars of soap in the bathtub and sink.
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Plan of Correction
Maintenance request has been submitted for any missing item in the bathrooms.
Clients soap is now in individual containers that are kept in their bedrooms when not in use.
All clients receive washcloths and towels for themselves and their children upon admission. When not in use, the wash cloths and towels are kept in the client's individual bedrooms.
All clients have individual soap dishes to keep bar soap in. When not in use the soap will be in the plastic container that has the individuals name on it. As part of the house manager's daily run, they will insure that soap is properly stored and that papertowels are available in all of the bathrooms.
Program Director and Building Maintenance will do monthly inspections with a checklist to insure compliance. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based upon observation, a physical plant inspection, and an interview with the clinical supervisor, the facility failed to maintain each bathroom in a functional, clean, and sanitary manner at all times.
The findings include:
A physical plant inspection was conducted on March 4, 2011 at approximately 9:30 AM and 11:30 AM and another physical plant inspection between 3:00 PM and 3:30 PM.
The girls restroom on the third floor was observed to have a toilet stall that was not functional. There was a sign on the restroom door that said "PLEASE DON'T USE TOILET THANK YOU!!!!."
The restroom on the first floor by the living room had a toilet stall that was not functional. There was a sign on the restroom door that said "OUT OF ORDER."
The clinical supervisor confirmed that the restrooms had signs posted and were not functional at the time of inspection.
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Plan of Correction
All toilets shall be in working order at all times. Should a toilet stop functioning, a maintenance request will be forwarded and the toilet seen to within 48 hours. House managers will inspect each toilet every day to insure proper functioning. |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based upon observation, a physical plant inspection, and an interview with the clinical supervisor, the facility failed to ensure that stairways, hallways and exits from rooms and from the residential facility were unobstructed.
The findings include:
A physical plant inspection was conducted on March 4, 2011 at approximately 9:30 AM and 11:30 AM and another physical plant inspection between 3:00 PM and 3:30 PM.
The emergency exit form the daycare, located in the basement, was obstructed.
The exit door from the daycare had a utility cart blocking the door on the inside and the outside of the emergency exit was obstructed with a trash can, trash and debris behind the door and on the steps, and there was a 4" x 4" x 8" piece of lumber behind the door.
The clinical supervisor confirmed that the emergency exit was obstructed.
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Plan of Correction
Obstruction from daycare exit has been removed. Daycare staff will inspect the stairwell on a daily basis to insure that it is free of obstruction and/or trash.
Director will inspect all exits weekly to insure staff is following up. |
705.10 (a) (1) (iii) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(iii) Maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18-inch drop with a well-secured railing.
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Observations
Based upon observation, a physical plant inspection, and an interview with the clinical supervisor, the facility failed to maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18-inch drop with a well-secured railing.
The findings include:
A physical plant inspection was conducted on March 4, 2011 at approximately 9:30 AM and 11:30 AM and another physical plant inspection between 3:00 PM and 3:30 PM.
The steps leading to the daycare center in the basement are steep and exceed two steps.
The handrail leading to the daycare center was loose and not secured. There was a hole in the wall and cracks at the top of the railing; the entire handrail was wobbly and unsafe.
The clinical supervisor confirmed that the handrail was loose.
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Plan of Correction
Stairwell railing was temporarilly fixed on 4/11/2011. Work on a new permanent railing will be done by 5/27/2011. Director has been in weekly contact with maintenance about the railing and inspects the railing daily. |
705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based upon observation, a physical plant inspection, and an interview with the kitchen supervisor, the facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company.
The findings include:
A physical plant inspection was conducted on March 4, 2011 at approximately 9:30 AM and 11:30 AM and another physical plant inspection between 3:00 PM and 3:30 PM.
There were two fire extinguishers located in the kitchen. One of the two fire extinguisher had not been inspected since July 2008.
The kitchen supervisor confirmed that the extinguisher had not been inspected since July 2008.
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Plan of Correction
As of 5/9/2011 all fire extinguishers were reinspected by the Boardman Co.
Housemanagers will inspect the extinguishers monthly to insure proper pressure. |
705.11 (2) (iii) LICENSURE Child care.
705.11. Child care.
(2) Interior space. The residential facility shall:
(iii) Maintain protective caps over each electrical outlet.
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Observations
Based upon observation, a physical plant inspection, and an interview with the clinical supervisor, the facility failed to maintain protective caps over each electrical outlet.
The findings include:
A physical plant inspection was conducted on March 4, 2011 at approximately 9:30 AM and 11:30 AM and another physical plant inspection between 3:00 PM and 3:30 PM.
The facility failed to maintain protective caps over each electrical outlet throughout the facility, from the daycare center, living room, to the bedroom.
Electrical outlets missing protective caps were observed in the daycare area, the living room, hallways, and bedrooms # 3, 4, and 7. In addition, there was a lamp without a lamp shade and without a bulb in it on a stand adjacent to a crib in bedroom#3. A child in the crib could easily reach the lamp and stick a finger/hand in the electrical socket.
The facility did during the physical plant inspection put protective caps on some of the electrical outlets; however, they were not able to replace each one as they ran out of the protective caps.
The clinical supervisor confirmed that protective caps were not maintained over each electrical outlet.
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Plan of Correction
All outlets are covered and inspected by house managers on a weekly basis.
The facility has a supply of covers on hand.
Childcare staff will inspect the childcare daily for covers. The house managers will inspect the hallways and bedrooms and living areas weekly for covers. The cook will inspect the kitchen weekly.
Director will do a run every two weeks to follow up. |
705.11 (2) (iv) LICENSURE Child care.
705.11. Child care.
(2) Interior space. The residential facility shall:
(iv) Secure all hazardous and poisonous substances and materials with safety latches or locks.
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Observations
Based upon observation, a physical plant inspection and an interview with the clinical supervisor, the facility failed to secure all hazardous and poisonous substances and materials with safety latches or locks.
The findings include:
A physical plant inspection was conducted on March 4, 2011 at approximately 9:30 AM.
Bedroom # 0 was observed with a container of bleach stored on the floor in a corner. The bleach was not secured out of reach of children.
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Plan of Correction
As of 3/5/2011, all bags are inspected to remove any hazardous materials. Room runs are done weekly. The laundry area is free of detergent and bleach at all times. Such items are stored in the locked basement storage closet.
Director does a run every two weeks for compliance. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of client medical records, and a review of the policy and procedures manual, the facility failed to document physical examinations per facility policy in seven of seven client records.
The findings include:
Seven client medical records were reviewed on March 4, 2011.
All records reviewed required documentation of physical examinations.
The facility failed to document physical examinations per policy in client records # 1, 2, 3, 4, 5, 6, and 7.
Facility policy titled Standard 709.51.b.5 Subject Physical Exam/Labs Dated January 2009, states:
A client entering a Gaudenzia (residential) program shall receive a complete physical examination by a qualified physician within 7 days of admission (DOH), except on holiday or weekend. Other exceptions are:
1.The client received a complete physical examination no longer than one month prior
to admission; that the program staff can obtain the results in writing;
and the nurse on duty is able to ascertain no noticeable medical problems.
1.[sic] Any physical examination not performed by the Gaudenzia physician will be
reviewed and signed off by him/her within 24 hours of client's admission to
the residential program.
2.[sic] Pennsylvania CBH clients are to have a completed physical within 72 hours -exceptions are holiday or weekend.
Documentation of the results of the physical examination shall include but not be limited to: evidence of injury, neurological findings, investigation of the organ systems for potential infectious disease, pulmonary, liver and cardiac abnormalities, dermatological sequelae of addiction, vital signs, examination of general appearance, head, ears, eyes, nose, throat, chest, abdomen, extremities, skin assessment, concurrent problems and the physician's overall impression of the client.
Client # 1 was admitted to the program on 8/16/10.
The physical examination reviewed in the medical record was dated and signed by a physician on 8/25/10; however, the physical did not include an examination of the client's general appearance, or the physician's impressions/diagnosis.
Client # 2 was admitted to the program on 9/1/10.
The physical examination reviewed in the medical record was dated
and signed by a physician on 9/3/10; however, the physical did not include an examination of the client's general appearance, or the physician's impressions/diagnosis.
Client # 3 was admitted to the program on 10/1/10.
The physical examination reviewed in the medical record was dated and signed by a physician on 10/5/10; however, the physical did not include an examination of the client's general appearance, or the physician's impressions/diagnosis.
Client # 4 was admitted to the program on 11/29/10.
The physical examination reviewed in the medical record was dated and signed by a physician on 11/30/10; however, the physical did not include an examination of the client's general appearance, or the physician's impressions/diagnosis.
Client # 5 was admitted to the program on 1/28/11.
The physical examination reviewed in the medical record was dated and signed by a physician on 2/4/11; however, the physical did not include an examination of the client's general appearance, or the physician's impressions/diagnosis.
Client # 6 was admitted to the program on 1/18/11.
The physical examination reviewed in the medical record was dated and signed by a physician on 1/24/11; however, the physical did not include an examination of the client's general appearance, or the physician's impressions/diagnosis.
Client # 7 was admitted to the program on 10/8/10.
The physical examination reviewed in the medical record was dated and signed by a physician on 10/15/10; however, the physical did not include an examination of the client's general appearance, or the physician's impressions/diagnosis.
This is a repeat citations.
The facility was previously cited for noncompliance of this standard during the 6/2/2010 Licensing inspection The facility's plan of correction submitted on 6/23/2010 and approved on 6/29/201 stated the following:
"Facility nurse will insure compliance with guidelines for having complete client physical within seven days from the date of admission. Facility nurse will review each physical for completeness and have physician complete any missing documentation. This will be added to facility's Quality Improvement Plan and monitored by Program Director monthly."
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Plan of Correction
Program Director took issue of physician's impressions to the Division Director of Women and Children's services. Division Director is taking the issue to the Executive Director. Physician's impression's need to be added to the physicial and the Executive Director will need to insure that the physician is compliant.
While the Winner program has not had any new admissions since June 1, it is expected that the next exam done by the physician will include physician's impressions.
6/24/11 - Per the Division Director of Women and Children's Services: When a physical exam is done, the facility nurse will review for completness. Any exam without physician's impressions will be immediately sent back to the physician for completion. The Division Director is also to be notified immediately by either the facility nurse or the Program Director. The exam will not be placed in the client record until complete. Any on-going issues with the physicians impressions will be taken to the Executive Director for corrective action. |
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 areas of noncompliance identified during this licensing inspection that had previously been cited, the facility failed to comply with a plan of correction approved by the Department.
The findings include:
On March 4, 2011 the facility was found to be out of compliance with standard 709.51(b)(5) Physical Examination. This area of noncompliance was also identified during the June 2, 2010 licensing inspection for which a plan of correction was submitted on June 23, 2010 and accepted and approved by the Department on June, 29, 2010.
Refer to tag 709.51(b)(5).
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Plan of Correction
Program Director informed the Division Director of Women and Children Services that physical exams need to take place within 3 days for Philadelphia County clients. Division Director is taking the issue to the Executive Director to insure physician's compliance. Facility Nurse is responsible for communicating the request for the physical to the agency's doctor. The Program Director will inform the Division Director immediately if there is a problem with compliance from the agency's physician.
After the June 1 inspection, the Program Director went to the Division Director who went to the Executive Director. The outcome is that the physician is to come into compliance with stating overall impressions on the physical exam form.
See 1517 for update information |