INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and compliant investigation conducted on April 26, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gaudenzia New Destiny 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 (1) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
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Observations
Based on a physical plant inspection on April 26, 2022, the facility failed to ensure that playground equipment was free from any danger to health and safety.
Several riding toys had rust and sharp edges on them where pieces had broken off.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Playground riding toys which had rust or sharp edges were removed from playground on 4/26/2022. In compliance with regulation 705.2, playground equipment on the grounds of the facility shall remain free from any danger to health and safety, New Destiny staff will inspect the playground equipment during monthly internal Health & Safety inspections. Playground inspection will be added to the daily house run sheet and staff instructed to remove unsafe items starting 5/2/2022. Program director will sign-off on monthly inspections |
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 April 26, 2022, the facility failed to ensure to provide an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
There was no soap dispenser in the bathroom shared by bedrooms 12 and 13.
There were no individual paper towels or a mechanical dryer in bathroom 203.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
All bathrooms, including private bathrooms, were checked and supplied with liquid soap dispensers and paper towels on 5/27/2022. In compliance with regulation 705.6, stating all facilities will provide an operable soap dispenser, and paper towels in each bathroom, checking on soap and paper towels was added to the House Run sheet, to be checked by New Destiny staff on duty, daily. Program Director will sign-off on this weekly. Adequete supplies and re-ordering will be done at weekly Administrative Meeting. |
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 on a physical plant inspection on April 26, 2022, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times.
The toilet seat was cracked in the first-floor bathroom.
There was no showerhead in the shower in the first-floor bathroom.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The cracked toilet seat in the first-floor bathroom was replaced on 5/2/2022. Shower head was installed on 5/18/2022. In compliance with regulation 705.6, all areas of the first-floor bathroom are functional, clean, and sanitary. Checking functionality in all bathrooms will be added to House Run Sheet, which is checked daily. Program director will sign-off on weekly basis. All maintenance issues will be discussed and work orders submitted for maintence repairs at weekly Administrative meeting.
The Quality Assurance department will conduct at least quarterly audits to include physical palnt inspections, and review of all POC Items to ensure full implemenation. |
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 on April 26, 2022, the facility failed to keep cold food at or below 40F.
There was a container of butter and a container of margarine sitting out uncovered on the kitchen counter at room temperature.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Community meeting was held on 4/27/22. Clients were informed to keep all cold food, specifically butter and margarine, covered and put back in refridgerator, after use. House managers were informed to check this particular issue during daily house runs. In compliance with regulation 705.7, butter and margarine is now kept in air-tight containers and stored in refridgerator after use. Checking this now added to House Run sheet. Program director will sign-off on a weekly basis. |
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 April 26, 2022, the facility failed to store all food items off the floor.
There were baby teething cookies stored on the floor in the walk-in pantry.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Community meeting was held with clients on 4/27/2022 to inform clients to be mindful of placing crates of baby food items off the floor and onto shelves. House managers were reminded that all pantry areas items need to be off of floor. Pantry areas are part of the kitchen house run. This will be part of regular/daily house runs and documented on House Run Sheets. Program director will sign-off on this weekly.This is compliance with regulation 705.7 stating that all food items are stored off the floor. |
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 on a physical plant inspection on April 26, 2022, the facility failed to ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
There was a ladder stored on the stairs in the second-floor fire escape.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Ladder was removed from stairs in the second-floor fire escape on 4/27/2022. In compliance with regulation 705.10, ensuring that all stairways, hallways, and exits from rooms and facility are unobstructed, staff members will check on areas after completion of any maintenance done in the building. This will be documented by checking visitor sign-in sheet and reported to Maintenance Manager of the region when outside maintenance contractors do work in the facility. Progrm director will contact Maintenance Manager and inspect area. |
705.29 (2) (i) LICENSURE Child care.
709.29. 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:
(i) Provide an interior play area which meets the developmental and recreational needs of the children in care.
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Observations
Based on a physical plant inspection on April 26, 2022, the facility failed to provide an interior play area which meets the developmental and recreational needs of the children in care.
There were limited activities for the older children (over age two) to participate in during recreational time.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The recreation area contains age-appropriate puzzles and games. Additional developmental and recreational needs are available for older children in shelving area of daycare room. The program will obtain additional age-appropriate items to enhance variety of choices. Program staff will encourage children to paly with these during recreation times in addition to other agge-appropriate activities or television programming. Progran Director and New Destiny staff will monitor this during daily walkthroughs of the faciltiy and will remind staff and mothers to encourage use of these resources.
The Quality Assurance department will conduct at least quarterly audits to include physical plant inspections, and review of all POC Items to ensure full implelmentation. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a review of administrative documents submitted, the project failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
The project's last annual financial audit was for the years ending June 30, 2020 and 2019.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
The Annual financial Audit for the most recent fiscal year(FY2020-2021) was not completed in a timely manner due to the delays on the part of the independent certified public accounting firm.
Amone these delays were the application of new standards regarding the review of all leased propertiessss(to include all real estate, business machines, and vehicles). This was a very laborious process that will not need to be repeated in the future.
Gaudenzia will obtain a completed financial audit from the the independent certified public accounting firm on or before September 30th of 2022.
In order to help ensuree that these delays do not occur in the future, the reorganized Fiscal department will begin preparation of all posiible documents required for the audit as early as possible in the year.
Leadership in this department reviewed the regulations in DDAP 709.25 on 4/26/22 in order to ensure that all understand the importance of timely completion of the Financial Audit.
THe Chief Financial Officer will oversee this process.
Completion Date: 9/30/2022 |
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 seven client records, the facility failed to document physical examinations within the 72-hour time frame listed in their policies and procedures in all records reviewed.
Client # 1 was admitted on October 19, 2021 and did not receive a physical exam until November 17, 2021.
Client # 2 was admitted on August 10, 2021 and did not receive a physical exam until November 19, 2021.
Client # 3 was admitted on January 3, 2022 and did not receive a physical exam until January 11, 2022.
Client # 4 was admitted on January 10, 2022 and did not receive a physical exam until February 1, 2022.
Client # 5 was admitted on November 22, 2021 and did not receive a physical exam until December 9, 2022.
Client # 6 was admitted on November 9, 2021 and did not receive a physical exam until December 1, 2021.
Client # 7 was admitted on January 11, 2022 and did not receive a physical exam until February 1, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Gaudenzia policy was revised on April 2022 to state that "A client entering a Gaudenzia (Residential) program shall receive a complete physical examination by a qualified physician or CRNP within 72 hours of admission at 3.5 and within 7 days at 3.1 (including weekends and holidays). Other exceptions are:
The client receives a complete physical examination no longer than 6 months prior to admission; that the program staff can obtain the results in writing; and the nurse on duty is able to ascertain no noticable medical problems. At programs with no medical staff, the Program Director will note review of the physical exam."
This change will be reviewed in our May CQI meeting. Program Director will then note review with the program staff to ensure that this revised policy is understood.
The Case Manager/Intake staff will request a copyof the physical exam from previous program at time of admission. A Medical Doctor has been engaged in order to complete physical exams within required timeframes. The CLinical Supervisor is responsible for coordination completion of physical exams.
The Clinical Supervisor will conduct weekly audits of a sample of charts and new admissions, in order to ensure that physical exams are completed/obtained for all admissions within the above-stated timeframes. Any missiing physicals will be completed within 48 hours.
THe Porgram Director will conduct monthly audits of a sample of charts in order to ensure that physcial exams are complete/obtained for all admissions within the above-stated timeframes. Any missing documentation will be brought to the attention of the Clinical Supervisor in order to coordinate completion within 48 hours.
The Quality Assurance department will conduct at least quarterly audits to include all POC items to ensure full implemenatation.
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709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in three out of seven records reviewed.
Client #2 was admitted on August 10, 2021 and was current at the time of the inspection. A treatment plan update was completed on February 23, 2022, with the next being due no later than March 23, 2022, but was but was not completed until March 25, 2022.
Client #3 was admitted on January 3, 2022 and was current at the time of the inspection. A treatment plan update was completed on February 1, 2022, with the next being due no later than March 1, 2022, but was not completed until March 4, 2022.
Client #4 was admitted January 10, 2022 and was still current at the time of the inspection. A treatment plan was completed on February 9, 2022, and the next was due by March 9, 2022, but was not completed until March 10, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In order to be in compliance with regulation 709.52, Individual treatment and Rehabilitation Plan, for 3.1. LOC, updated treatment plans must be completed within 30 days of previous treatment plan. Clinical staff reviewed the policy and procedure and the 3.1 Workflow to be in compliance on time-frames from initial, comprehensive, and updated treatemnt plans. Clinical staff will send all treatment plans to Clinical Supervisor for approval before submitting. Calenders are being utilized to keep close track of time-sensitive dates for each client. Upcoming updated treatment plans will be reviewed in weekly Clinical Staff meeting. |