INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 7, 2025, 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. Fountain Springs 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 (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 on a physical plant inspection on May 7, 2025, the facility failed to keep the ground of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors.
Locked heater plates were bent in rooms 102 and 104, allowing access to the interior wiring and sharp metal parts of the heater.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
A work order was immediately completed to have these plates replaced. The plate has now been removed, the opening has been covered with no access to interior wiring, and sharp metal plates were filed down to avoid injury while awaiting new plates. The replacement of the new plate should be completed by the end of June 2025. The house runs sheet was updated to include a plate covering to be checked in each room when house runs are complete, and added to the room condition sheet, which is checked before a new client moves into that room.
Staff, the Program Director, and Maintenance will monitor ongoing compliance through monthly review of the run sheets.
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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 the review of four personnel records and staff training records, the project failed to instruct one staff in the use of the fire extinguisher upon employment.
Employee #3 was hired as the facility director on June 24, 2024, and was current in that position at the time of the inspection. The employee was to be instructed in the use of the fire extinguisher upon employment; however, the employee did not receive this training until July 8, 2024.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
This has been corrected and updated on the individual training plan generated for all new hires on their first day. The plan is checked at the end of each day to ensure training is completed by the due date and recorded in our web-based Relias training system. Moving forward, staff complete this training on the very first day of employment at the facility.
The Administrative Assistant and Program Director will monitor ongoing compliance to ensure training is completed through daily review of training documentation for new hires and quarterly review of training documentation for all other employees. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on the review of four personnel records and staff training records, the project failed to ensure that one staff was trained to perform assigned tasks during emergencies.
Employee #3 was hired as the facility director on June 24, 2024, and was current in that position at the time of the inspection. The employee was to be trained to perform assigned tasks during emergencies prior to working a shift; however, the employee did not receive this training until July 8, 2024.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
This has been corrected and updated on the individual training plan generated for all new hires on their first day. The plan is checked at the end of each day to ensure training is completed by the due date and recorded in our web-based Relias training system. Moving forward, staff complete this training on the very first day of employment at the facility.
The Administrative Assistant and Program Director will monitor ongoing compliance to ensure training is completed through daily review of training documentation for new hires and quarterly review of training documentation for all other employees. |
705.11 (2) (ii) LICENSURE Child care.
705.11. Child care.
(2) Interior space. The residential facility shall:
(ii) Maintain security screens or safety locks for all operable windows.
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Observations
Based on a physical plant inspection on May 7, 2025, the facility failed to maintain security screens or safety locks for all operable windows.
Safety screens and/or safety locks were missing for windows in rooms 107 and 110.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
A maintenance order was immediately completed to have the screen installed. Screens were installed on 05/15/2025. Window screens have also been added to be checked on the daily house run sheet, and the staff completed the room inspection sheet upon the client's arrival to the room.
The RSP, RSP Supervisor, Program Director, and Maintenance will monitor ongoing compliance through monthly review of the run sheets. |
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 on a physical plant inspection on May 7, 2025, the facility failed to maintain protective caps over each electrical outlet.
An electrical outlet in room 109 had a broken faceplate and did not have protective caps on it.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
A work order was immediately completed to replace the faceplate with a new one with a built-in child protective cover. Repairs were completed on 5/30/2025.
The RSP and Program Director will monitor compliance on an ongoing basis, and maintenance will be done through monthly review of the run sheets. |
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 the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one of seven client records reviewed.
Client #2 was admitted on March 6, 2025 and was a current client at the time of the inspection. A facility staff member communicated with an elementary school staff member regarding the client ' s child on April 28, 2025; however, a release of information form was not documented in the record prior to the disclosure.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The client's chart has been updated with consent for the child's school on 05/08/2025. The prevention specialist workflow has been updated to indicate that school consent must be signed when the client and Prevention Specialist first meet for consent to the school district within the program if a child leaves that school for another school while at a program, consent will be completed before the child's first date at the new school.
Prevention staff and the program director will complete ongoing compliance monitoring during monthly chart reviews. |
709.32 (c) (6) LICENSURE Medication control
§ 709.32. Medication control.
(6) Medication errors and drug reactions shall be recorded in the client record. This may be the medical record if a separate medical record is maintained for all clients.
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Observations
Based on a review of seven client records, the facility failed to record medication errors in the client record in five of seven records reviewed.
Client #1 was admitted on February 26, 2025 and was a current client at the time of the inspection. This client was prescribed Nortriptyline one time a day, at bedtime; however, there is no documentation that the client received or refused this medication on April 2, 2025, April 3, 2025, April 17, 2025, or May 2, 2025.
Client #3 was admitted on March 27, 2025 and was a current client at the time of the inspection. This client was prescribed Advair one inhalation, two time a day; however, there is no documentation that the client received or refused the second dose of this medication on March 30, 2025, or April 30, 2025.
Client #4 was admitted on October 14, 2024 and was discharged on January 27, 2025. This client was prescribed Zoloft one time a day; however, there is no documentation that the client received or refused this medication on October 25, 2024, or November 28, 2024.
Client #5 was admitted on October 9, 2024 and was discharged on March 10, 2025. This client was prescribed Buspirone two time a day; however, there is no documentation that the client received or refused the second dose of this medication on January 15, 2025, February 15, 2025, or March 3, 2025.
Client #7 was admitted on January 16, 2025 and was discharged on April 18, 2025. This client was prescribed Remeron one time a day, at bedtime; however, there is no documentation that the client received or refused this medication on March 12, 2025.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Program Director discussed the issue with any staff responsible for medication administration and/or observation. Staff were notified that they need to enter the missed dose and the reason for the medication being scheduled for anyone who missed it for any reason. The program nurse will also monitor eMAR each shift for missing doses and reasons. This will be further mitigated with an increase in the number of nursing staff available 24 hours per day beginning in July.
Nursing staff and the Program Director will monitor compliance on an ongoing basis during monthly reviews of a sample of charts. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on the review of the unusual incident log, the project failed to file a written unusual incident report with the Department within three business days following an unusual incident involving an event at the facility requiring the presence of police, fire or ambulance personnel.
On March 10, 2025, police were contacted and arrived at the facility to assist a patient. A written unusual incident report was not filed with the Department.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Program Director developed an Excel spreadsheet to track the filing of DDAP reports in the portal. In the Program Director's absence, the Clinical Supervisor will be responsible for filing incident reports to the DDAP portal. A binder was assembled for reportable incidents and tracking incidents.
The internal incident report and the DDAP report will be stapled together and stamped with the date and time they were submitted. They will also be reviewed weekly to ensure they are entered in the DDAP web portal.
The Program Director and Clinical Supervisor will monitor ongoing compliance. |