INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 8, 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. 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 First Aid certifications provided by the facility, the facility failed to ensure that at least one person trained in First Aid was onsite during the project's hours of operations. The following 05:00 p.m. - 12:00 a.m. shifts did not have staff trained in First Aid:
4/24/23
4/26/23
4/27/23
4/28/22
5/8/23
5/10/23
5/11/23
5/12/23
5/15/23
5/17/23
5/18/23
5/19/23
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
There was one RSP Staff that did not have her First Aid. RPS did have the CPR. RSP Completed her First Aid certification on 7/6/2023 and her certification is in the file. Her First AID and CPR has been submitted to DDAP representative. Program director will oversee that it does not happen again by making sure at least one staff with CPS/First aid is scheduled with staff until new staff is certified. |
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 June 8, 2023, the facility failed to keep the grounds of the facility clean, safe, and sanitary as the playground area contained an overfilled garbage can, an open and overflowing bag of garbage, as well as litter.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The onsite playground was cleaned by staff and residents as the therapeutic cleaning activity on 6/11/23. The chore has been added to the therapeutic activities' chore for weekly cleaning and has been ongoing since 6/11/23. On 7/5/23 the facilities staff came and cut the grass and that will be ongoing and managed by the program director. The acquisition form has been submitted on 7/8/23 for four new industrial trash cans with attached lids to prevent further overflow. They are expected to arrive by 7/31/23. Our maintenance director is working on getting Hutchinson Place a 3rd day of trash pick-up. The Program Director is responsible for follow-up. Until then the extra trash cans will prevent any overflow. |
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 8, 2023, the facility failed to ensure that garbage was stored in covered containers that prevent the penetration of insects and rodents as there were two uncovered garbage cans immediately outside of the building and one uncovered garbage can inside the playground area.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 6/11/23 the playground was cleaned by residents and staff. All the trash and debris were removed. The acquisition form has been submitted on 7/8/23 for four new industrial trash cans with attached lids to prevent further overflow. Our maintenance director is working on getting Hutchinson Place a 3rd day of trash pick-up. The Facility Director is responsible for follow-up. Until then the extra trash cans will prevent any overflow. |
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 June 8, 2023, the facility failed to provide either individual paper towels or a mechanical dryer in each bathroom as neither were in the shared restroom on the second floor.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 6/8/23 Director stocked the restroom with paper towels immediately once it was discovered that there were none in the restroom. Director also had a meeting with staff on duty about keeping paper towels stocked in the restroom. The house manager will oversee that the restrooms always have stocked paper towels by keeping an overflow of paper towels in the restroom and having overnight staff stocked restrooms every morning before end of shift. |
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 June 8, 2023, the facility failed to keep frozen food at or below 0 degrees Fahrenheit, as a standing freezer was 10 degrees.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 6/8/2023 the freezer temperature was lowered to be sure the temperature is reading 0 degrees F. The cook was trained on recording the temperature and making sure it is at 0 degrees F. The refrigerator work order was submitted to be serviced. We also had to contact the manufacturer. The food has been placed in an alternative refrigerator on-site until the refrigerator in question temperature is working properly. The cook will oversee all freezer and refrigerator temperatures are correct. |
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 a review of four personnel records, the facility failed to ensure that each staff was instructed in the use of the fire extinguishers upon employment in two records reviewed.
Employee #2 was hired as the Facility Direction on August 15, 2023 and was due to be trained in the use of fire extinguishers upon employment; however, the record contained no documentation that fire safety training was completed as of the date of the inspection.
Employee #3 was hired as a counselor on October 3, 2022 and was due to be trained in the use of fire extinguishers upon employment; however, fire safety training was not documented as complete until March 28, 2023.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On the day of inspection every employee that has been hired and currently work at Hutchinson Place has had fire safety training. The director will continue to oversee that every employee that is hired will be trained within the first 5-days of hire ongoing. Moving forward records will be ready to present at the time of the DDAP inspection in a folder by program director. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the fire drill logs from July 2022 through May 2023, the facility failed to conduct unannounced fire drills at least once a month as no fire drills were conducted during July, September, November, or December 2022 or January, February, March, April, May 2023.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 6/9/2023 the Program Director met with the house manager supervisor and went over the attestation. Starting June 2023, we begun to complete unplanned fire drills 1x monthly. The program director will sign off on the fire drill monthly. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of fire drill logs from July 2022 through May 2023, the facility failed to ensure that fire drill logs included the exit route used for the August and October 2022 fire drills conducted.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 6/9/2023 Program director met with the house manager supervisor to review the correct fire drill logs for DDAP. The correct logs have the exit route included and will be used moving forward. The House manager supervisor will be sure the correct logs are being used. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of fire drill logs from July 2022 through May 2023, the facility failed to conduct fire drills during sleeping hours at least every six months.
Based on the program schedule provided by facility staff, the unit sleeping hours are 11:00 P.M. through 07:00 A.M. No fire drills between July 2022 and May 2023 were conducted between those hours.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 6/9/2023 The program director went over the attestation with the house manager supervisor (who oversees the fire drills). Moving forward fire drills will be conducted monthly with every other fire drill being on the overnight. An overnight, unannounced fire drill was completed in June 2023. House manager supervisor and program director will be responsible to the POC is implemented accordingly. |
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 June 8, 2023, the facility failed to maintain protective caps over each electrical outlet as an outlet in the shared bathroom on the second floor did not have a protective cap.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director brought extra socket covered any sockets that did not have built in covers. All sockets at Hutchinson Place have socket covers if not in use. House Manager supervisor will assign RSP on shift to do a walk-thru 1x daily to check that all the sockets have covers and sign a facility shift log. RSP house manager will keep track that the plan is being implemented as planned. |
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 one of one applicable record reviewed.
Client # 2 was admitted on March 4, 2022 and was discharged Against Staff Advice (ASA) on August 2, 2022. 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
Program director sat with both counselors to inform them of the findings. None of the current employees were hired at the time including the program director but I reiterated the policy on ASA. It will be the counselors' responsibility to call the emergency contact on file if a member ASA's. Director will also oversee that the emergency contact gets called in 12 hours if there is an ASA. |
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 two records reviewed.
Client # 4 was admitted on October 14, 2022 and was discharged on November 22, 2022. The consent to release information form to the funding source was not signed until October 31, 2022, and there was evidence of billing prior to the client signed consent to release information form.
Client # 6 was admitted on March 6, 2023 and was active at the time of the inspection. The record did not contain a consent to release information form to the funding source, however, there was evidence of billing.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
6/14/2023 The intake staff has been trained to have the funding release signed the day of admission. The counselors were also trained that the funding consent be signed the day of admission and UR could not be completed unless the consent is sign and they must make sure its sign before UR's are completed. The program director will be sure to do weekly audits to make sure POC is being implemented. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records and the facility's policies and procedures, the facility failed to document an individual treatment and rehabilitation plan within 30 days of the preliminary treatment plan, in two of six applicable records reviewed.
Client # 3 was admitted on August 15, 2022 and was discharged on April 2, 2023. The preliminary treatment plan was completed on August 26, 2022, and the individual treatment and rehabilitation plan was due to be completed by September 26, 2022; however, it was not completed until October 10, 2022.
Client # 6 was admitted on March 6, 2023 and was active at the time of the inspection. The preliminary treatment plan was completed on March 10, 2023, and the individual treatment and rehabilitation plan was due to be completed by April 10, 2023; however, it was not completed until April 27, 2023.
These finding were discussed with facility staff during the licensing process.
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Plan of Correction
The clinical staff was retrained on the workflow of documentation. More importantly that the comprehensive treatment plan must be completed within in 30-days of admission. Director will do weekly clinical audits to make sure documentation is being completed on time. |