INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on May 29, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Common Ground 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of personnel records and the facility staff schedule, the facility failed to provide at least one person in CPR certification and first aid training onsite during the following dates and hours:
March 11- 7pm- 11pm
March 12- 7am-8am and 5pm- 11pm
March 13- 5pm-11pm
March 14- 7pm-11pm
March 16- 12:01am-9am
March 17- 7am-9am
March 18- 8pm-11pm
March 19- 5pm-11pm
March 20- 5pm-11pm
March 21- 5pm-11pm
March 23- 12:01am-7am
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Moving forward all staff
will be trained in CPR and
First Aid.
The Program Director and
Clinical Supervisor will
ensure that all current
program staff will complete
CPR and First Aid training
by 7/31/24.
Moving Forward the
Program Director and
Clinical Supervisor will
monitor staff training needs
monthly to ensure that all
CPR/First Aid certifications
are up to date. |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
|
Observations
Based on a physical plant inspection, the bathroom located in the women ' s detox had a water temperature of 127 degrees.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Program Director has
contacted maintenance to
services the boilers.
Program Director will
complete quarterly checks
and document water
temperatures. If water
temperatures are over
120F, maintenance will be
notified. |
705.6 (6) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(6) Provide toilet paper at each toilet at all times.
|
Observations
Based on a physical plant inspection, the single bathroom did not provide toilet paper at all times. There was no toilet paper present during the inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Program Director will
review with staff no later
than 7/31/24 the
requirements for keeping
all bathrooms stocked with
toilet paper.
Recover Support Staff will
monitor bathroom supplies
to include toilet paper during daily facility checks
and document on a daily
facility inspection log.
|
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.
|
Observations
Based on a physical plant inspection, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times. The men's main bathroom showers had what appeared to be mold around the shower base and the shower curtains.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The shower curtains in the
men's bathroom have been
replaced as of 6/10/24.
Program Director will
review with staff during the
next all staff meeting no
later than 7/31/24, the
requirements and
appropriate cleaning
practices for all bathrooms.
Recovery Support Staff will
check facility bathrooms
daily to ensure all area's are
clean and document on a
daily facility inspection log. |
705.7 (b) (3) 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:
(3) Clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
|
Observations
Based on a physical plant inspection, the facility failed to keep cooking and eating utensils in a clean and enclosed area. Cooking utensils were being stored hanging in an open area in the kitchen. Plasticware was being stored in the cafeteria in bins that were not covered.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Program Director will meet
with the cook to review
proper procedures for
cleaning and storing of
utensils.
Moving forward all cooking
utensils will be stored in an
enclosed container.Program Director will
complete monthly checks
to ensure utensils are
being stored properly.
This will be documented
in a facility inspection log. |
705.10 (c) (2) (ii) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(2) Maintain at least one portable fire extinguisher with a minimum of an ABC rating in each kitchen.
(ii) The extinguisher shall be located near an exit and away from the cooking area.
|
Observations
Based on a physical plant inspection, the facility failed to maintain a portable fire extinguisher near an exit and away from the cooking area. The fire extinguisher in the kitchen was located on the wall next to the cooking area.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Director put in a work order on 5/30/24 to move the fire extinguisher, maintenance department addressed the issue and bas installed it to the wall
near the exit in the back of
the kitchen area.
The RSP will complete monthly inspections of all fire extinguishers. to ensure they are up to date in the right location per regulations. This will be documented in a facility inspection log.
|
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.
|
Observations
Based on two of two applicable client records reviewed, the facility failed to provide documentation of the emergency contact being notified when a client leaves against medical advice in accordance with the facility policy and procedure manual. The facility policy and procedure indicate the emergency contact be notified of the client leaving against medical advice within 12 hours of leaving and documented in the client record.
Client # 3 was admitted on March 19, 2024, and was discharged on March 21, 2024. There was no documentation of the emergency contact being notified of the client leaving against medical advice in the client record.
Client # 13 was admitted on February 29, 2024, and was discharged on March 3, 2024. There was no documentation of the emergency contact being notified of the client leaving against medical advice in the client record.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Program Director will
review with staff during
the next all staff meeting
the requirements for
notifying and documenting
emergency contacts within
12 hours of a client
leaving ASA by 7/31/24.
Clinical Supervisor will
audit discharge charts
monthly to include the
notification of emergency
contacts for clients that
are ASA discharges.
CQI Department will
review a sample of
discharge charts during
semiannual audits.
|
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
|
Observations
Based on a review of personnel records, the facility failed to ensure that annual written individual staff performance evaluations, were reviewed and signed by the employee per the facility's policy and procedure manual in two out of three personnel records reviewed. The facility's policy and procedure manual states that the annual job performance evaluations are due at the beginning of each calendar year. Project staff indicated evaluations specifically are to be completed and signed by February 1 each year.
Employee # 1 was hired as the Project Director on September 9, 2019 and is current in that position. The annual written staff performance evaluation was due to be reviewed and signed by the employee by February 1, 2024, however, it was not signed by the employee until February 28, 2024.
Employee # 2 has been in the position of Facility Director since October 31, 2022. The annual written staff performance evaluation was due to be reviewed and signed by the employee by February 1, 2024, however, it was not signed by the employee until February 8, 2024.
Employee # 3 has been in the position of Clinical Supervisor since October 24, 2022. The annual written staff performance evaluation was due to be reviewed and signed by the employee by February 1, 2024, however, it was not signed by the employee until February 5, 2024.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
no later than February 1st
of each year.
The Chief Executive Officer
will ensure that this process
is completed for the Project
Director.
The Deputy Directors will
ensure that this process is
completed for all Division
Directors.
The Division Directors will
complete Annual
Performance Evaluations
for each of the Program
Directors that they oversee,
and will also ensure that
these Program Directors
complete Annual
Performance Evaluations
for the staff that they
overseeThe Quality Assurance
department will review
staff files during semiannual program reviews to
ensure compliance |
709.53(a)(10) LICENSURE Discharge Summary
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(10) Discharge summary.
|
Observations
Based on three of four applicable client records reviewed, the facility failed to provide a discharge summary in accordance with the facility policy and procedure manual. The policy and procedure manual indicates a discharge summary be completed within 7 days of discharge.
Client # 11 was admitted on January 12, 2024, and was discharged on January 19, 2024. The discharge summary was not documented in the record.
Client # 12 was admitted on December 27, 2023, and was discharged on February 6, 2024. The discharge summary was not documented in the record.
Client # 14 was admitted on April 2, 2024, and was discharged on May 8, 2024. The discharge summary was not documented in the record.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Program Director and
Clinical Supervisor will
review with staff during the
next clinical meeting the
requirements and time
frames for completing
discharge summaries.
The Clinical Supervisor will
audit discharge charts
monthly for completed
discharge summaries.
CQI department will audits
discharge charts on a
semiannual basis |