INITIAL COMMENTS
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This report is a result of an on-site licensure inspection conducted on June 4, 2010 by staff from the Division of Drug and Alcohol 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 and a plan of correction is due on July 1, 2010.
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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 the Staffing Requirements Facility Summary Report and an interview with the facility director on June 4, 2010, the facility failed to ensure that staff persons and volunteers received a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD and other health related topics within the first year of employment for clinical staff and within two years of employment for non-clinical staff.
The findings include:
Three employees were reviewed for having completed the HIV/AIDS and STD/TB training.
All three were required to have completed the HIV/AIDS and STD/TB training, employee # 3 failed to complete the training within the allotted timeframe.
Employee # 3 was hired on 1/28/08.
Employee # 3 is non-clinical staff.
At the time of review on 6/4/10 employee # 3 had not received the STD/TB.
The facility director confirmed that employee # 3 did not complete the STD/TB training within the first 2 years of employment.
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Plan of Correction
Program Supervisor will monitor all staff trainings and training hours to ensure all staff persons and volunteers receive the minimum of 6 hours of training for HIV/AIDS and at least 4 hours for training for tuberculosis, sexually transmitted diseases and other health related topics within the first year of employment for clinical staff and all other staff persons within the two year requirement time. Employee #:3 have been scheduled to attend TB/STD trainig on 9/3/2010. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of the facilities training files it was determined that the facility director did not have the minimum training hours for their annual training year.
The findings include:
A review of the facility director ' s training file revealed that the required twelve clock hours of training annually was not complete.
The facility director only completed five training hours for the year ending.
The facility director confirmed that he did not complete the required twelve hours of training.
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Plan of Correction
Program Supervisor has/will complete a minimum of 12 clock hours of training that is required annually in areas such as: Fiscal Policy. Program Supervisor has scheduled trainings for the 2010 year. |
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 an inspection of the physical plant and an interview with the facility director, the facility failed to keep cold food at or below 40 degrees, hot food at or above 140 degrees, and frozen food at or below 0 degrees, as required by regulation.
The findings include:
The facilities kitchen and food storage area was inspected on June 4, 2010 at approximately 10:00 AM and 1:45 PM.
Per regulation, a residential facility that operates an onsite food preparation area or a central food preparation area shall keep frozen food at or below 0 degrees, one out of two freezers in the facilities basement had a temperature greater than 0 degrees.
The thermometer in the freezer read a temperature of 15 degrees at the first physical plant inspection which occurred at approximately 10 AM.
The facility director rearranged the food in the freezer and another inspection of this freezer occurred at approximately 1:45 PM at which time the thermometer in the freezer read a temperature of 10 degrees.
The facility director confirmed at the time of both physical plant inspections that the temperatures were 15 degrees and 10 degrees respectively and that frozen food was not at or below 0 degrees.
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Plan of Correction
Program Supervisor submitted work order for freezer. Freezer was serviced and is now operating at 0 degrees. Program Supervisor has implemented a temperature check list for each shift to read the thermometers and document temperatures every hour to ensure that frozen food is kept at 0 degrees or below and cold food is kept at a temperature at or below 40F degrees. |
705.10 (b) (3) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(3) Repair inoperable smoke detectors or fire alarms within 48 hours of the time the detector or alarm is found to be inoperative.
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Observations
Based on the review of administrative documentation and an interview with the facility director, the facility failed to repair inoperable smoke detectors or fire alarms within 48 hours of the time the detection or alarm is found to be inoperative.
The findings include:
On June 4, 2010 the facilities fire drill log was reviewed.
The log documented three fire drills during the month of January 2010, 1/6/10, 1/15/10, and 1/30/10.
On 1/6/10 and 1/15/10 the log indicated that the alarm was pulled.
On 1/30/10 the log documented that the alarm was not pulled and it also indicated "voice."
For the month of February 2010, the facility documented three fire drills, 2/18/10, 2/13/10, and 2/23/10.
On all three dates the log indicated that the alarm was not pulled and it also indicated either "voice" or "by mouth."
An interview with the facility director was conducted and the facility director confirmed that the fire alarm was inoperative for more than 48 hours.
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Plan of Correction
Program Supervisor submitted work order for alarm system. Alarm system was serviced and is operating as it should. Program Supervisor will have alarm system serviced each month by Philadelphia Detection System Inc.to ensure alarm is always operational. |