INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 18, 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 Focus House 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 personnel records, the facility failed to ensure that one of three applicable employees received 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 within the regulatory timeframe.
Employee #3 was hired as a support staff member on February 1, 2021 and was due to have the communicable disease trainings no later than February 1, 2023. However, the personnel record contained no documentation of the completion of the HIV/AIDS or TB/STD trainings as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
What we did to address: The Program Supervisor will seek out a training that meets the six-hour requirement, or trainings that equal the six-hour requirement. DDAP offers these trainings, however, the training on June 9, 2023 is full. There is a training that is available on June 13, 2023 that the Program Supervisor has submitted to receive the final three spots.
Who will be responsible to address moving forward: The Supervisor will be responsible for the implementation of the additional educational needs and will continue to search for the available course requirements.
How you will address moving forward: The Program Supervisor has consulted with the Division Director to ensure the implementation of this requirement through the DDAP Training site.
How often you will address: This will be addressed yearly as a requirement.
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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 on a physical plant inspection on May 18, 2023, the facility failed to provide an operable soap dispenser in the third-floor bathroom.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
What we did to address: We have submitted a maintenance request to have the soap dispensers replaced. While waiting for the maintenance department, hand soap was purchased as a stopgap until the dispensers can be installed.
Who will be responsible to address moving forward: The Program Supervisor is responsible for ensuring that the soap dispensers are installed in each bathroom.
How you will address moving forward: The Program Supervisor has added to the duties of the Recovery Support Professional to inspect all areas to ensure that soap dispensers are working, in good repair, and filled with soap.
How often you will address: This will be addressed when the 11-7 am shift does his daily inspection. |
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 May 18, 2023, the facility failed to ensure that heaters were permanently mounted as a space heater was found in the restroom in the rear of the first floor.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
What we did to address: The space heater was removed from the bathroom.
Who will be responsible to address moving forward: The Program Supervisor will be responsible for ensuring that space heaters are not brought into the facility without proper authorization. The Program Supervisor has added to the duties of the Recovery Support Professional to inspect all areas to ensure that no space heaters were brought into the facility.
How you will address moving forward: There is an exception being submitted for the space heater by the Division Director, while daily checks have been implemented.
How often you will address: If the exception is granted, then the issue is resolved. Should the exception not be granted, then the door will have to be left open so as to let the heat circulate into that bathroom. The Program Supervisor has added to the duties of the Recovery Support Professional to inspect all areas to ensure that no space heaters were brought into the facility. |
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 client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients. The facility failed to follow their policy related to ASA discharges of calling the Emergency Contact within twelve hours in three of three applicable records reviewed.
Client # 2 was admitted on June 7, 2022 and discharged Against Staff Advice (ASA) on June 10, 2022. There was no documentation in the client record that the emergency contact was called.
Client # 3 was admitted on November 29, 2022 and discharged Against Staff Advice (ASA) on December 6, 2022. There was no documentation in the client record that the emergency contact was called.
Client # 4 was admitted on April 4, 2023 and discharged Against Staff Advice (ASA) on May 8, 2023. There was no documentation in the client record that the emergency contact was called.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
What we did to address: The Program Supervisor has instituted the rule that the emergency contact, as well as the assigned supportive case manager must be notified within 12 hours of the ASA by the Recovery Support Specialist.
Who will be responsible to address moving forward: The case manager on site will be responsible for following up with the emergency contact, and supportive case manager.
How you will address moving forward: The information concerning when the contact was initiated will be entered on the incident report by the Recovery Support Specialist, and in the note written by the on-site case manager following the ASA.
How often you will address: This will be addressed immediately following each ASA. The Program Supervisor will conduct an audit every thirty days to ensure that this is being done in accordance with the new guidelines. |
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 prior to disclosing information in one record reviewed.
Client #1 was admitted on August 16, 2022 and discharged on November 9, 2022. The record contained documentation of contact with a parole officer on September 9, 2022, to whom the record contained no informed and voluntary consent to release information form signed by the client.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
What we did to address: The Program Supervisor will ensure that each resident with probation/ or parole has a signed consent in their chart. They will sign consent prior to staff speaking with their PO, as it is their choice whether or not they agree to sign the consent.
Who will be responsible to address moving forward: The Program Supervisor will be responsible for this, as each resident signs their consents with the Program Supervisor now.
How you will address moving forward: The Program Supervisor will initiate this process during in processing to ensure that the residents' privacy is thoroughly protected.
How often you will address: This issue will be addressed upon entry of each new resident. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of seven records, the facility failed to ensure that informed and voluntary consent to release information forms included the specific information to be disclosed in four records reviewed.
Client # 4 was admitted on April 4, 2023 and discharged on May 8, 2023. The record contained a consent to release information forms to probation/parole signed by the client on April 6, 2023, that was missing the specific information to be disclosed.
Client # 5 was admitted on March 14, 2023 and was active at the time of the inspection. The record contained consent to release information forms to probation/parole, the funding source, a government agency, and a lab signed by the client on March 14, 2023, that were missing the specific information to be disclosed.
Client # 6 was admitted on April 21, 2022 and was active at the time of the inspection. The record contained consent to release information forms to the funding source and a government agency signed by the client on January 26, 2023, that were missing the specific information to be disclosed.
Client # 7 was admitted on November 15, 2022 and was active at the time of the inspection. The record contained consent to release information forms to the funding source, a treatment provider, and a government agency signed by the client on January 26, 2023, that were missing the specific information to be disclosed.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
What we did to address: The Program Supervisor will ensure that each release of information provides more specifics regarding the limits of its use. The Consents will begin to be revised beginning 06/07/2023.
Who will be responsible to address moving forward: The Program Supervisor has already begun to revise each consent to add the proper language to limit the consents to specific information. This will be completed by 06/21/23.
How you will address moving forward: The Program Supervisor will initiate this process during in processing with the new language. The facility, specifically the Program Supervisor will ensure that informed and voluntary consent to release information include the specific information to be disclosed to separate entities.
How often you will address: This issue will be addressed with each current resident with updated consents, and upon entry of each new resident, and each year during renewal. There will be a review of all consents by the Division Director to ensure that each chart has the adequate consent information. Each consent will be tailored to the needs of each resident of the facility. |
709.32 (c) (2) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(2) Drug storage areas including, but not limited to, the secure storage of controlled substances and other abusable drugs in accordance with State and Federal regulations and program requirements.
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Observations
Based on a physical plant inspection on May 18, 2023 at 09:45 a.m., the facility failed to follow their policy and procedures related to securing drug storing areas. The facility policy states: "The door to the medication area is secured by one knob lock and one deadbolt lock and the medication cabinets are under separate lock. " The medication room was unoccupied and the door to the medication room was propped open while the medication cabinet was unlocked.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
What we did to address: Staff was informed that the door has to remain shut at all times when not in the medication room.
Who will be responsible to address moving forward: The Program Supervisor is responsible for the security of the medication room.
How you will address moving forward: This issue has already been addressed.
How often you will address: The Program Supervisor will make routine checks of the medication room, and the facility. |
709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
Based on a review of seven client records, the facility failed to follow their policy and procedures related to medication administration and recordkeeping in five of six applicable records reviewed. The facility policy indicates that staff will document on the medication administration record (MAR) the reason a medication was not given. Additionally, medication administration forms will include date and time of administration.
Client #1 was admitted on August 16, 2022 and discharged on November 9, 2022. The MAR for October and November 2022 appeared to be mislabeled and reversed, indicating that the client was administered medications after they were discharged.
Client # 3 was admitted on November 29, 2022 and discharged on December 6, 2022. The MAR in December 2022 did not document whether a medication was taken or the reason it was not administered on December 1, 2022 through December 5, 2022.
Client # 5 was admitted on March 14, 2023 and was active at the time of the inspection. The record contained a MAR that was not labeled with the complete date of administration to include the month.
Client # 6 was admitted on April 21, 2022 and was active at the time of the inspection. The record did not contain MAR records for June or July 2022 and there was evidence that medications were administered during this period.
Client # 7 was admitted on November 15, 2022 and was active at the time of the inspection. The MAR in November 2022 did not document whether a medication was taken or the reason it was not administered on November 23, 2022 through November 30, 2022.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
What we did to address: The Program Supervisor was informed by the Division Director that there will be a Mandatory Medication Training hosted at this facility on June 7, 2023. A Recovery Support Professional has already initiated organizing the MAR's sheets in a newly purchased binder to make them more accessible.
Who will be responsible to address moving forward: The Program Supervisor will be responsible for ensuring that this is properly addressed.
How you will address moving forward: The Program Supervisor will ensure that additional training is initiated for each member of Focus House.
How often you will address: This should be addressed quarterly. |