INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 14, 2017 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Gaudenzia, Inc. Re-Entry 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
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Plan of Correction
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704.12(a)(3)(i) LICENSURE NonHosp Rehab
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(3) Inpatient nonhospital treatment and rehabilitation (residential treatment and rehabilitation).
(i) Projects serving adult clients shall have one FTE counselor for every eight clients.
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Observations
The Staffing Requirements Facility Summary Report (SRFSR) form was completed and reviewed during the licensing process. The form listed two counselors. Based on the total number of hours per week that the facility reported the employees devoted to their clients and the total number of active drug and alcohol clients, as of the date of the inspection, the facility exceeded the allowable maximum 8:1 full time equivalent (FTE) client to counselor ratio for an inpatient program.
The FTE ratio is determined by dividing the total number of hours the facility devotes to the clients by 35. The result is the facility's FTE. Then, to obtain the facility's client/counselor ratio, the total number of clients the facility currently has is divided by the facility FTE.
The number of hours per week devoted by the entire facility, as reported on the SRFSR, was 80 hours. The facility also reported on the SRFSR that the total number of drug and alcohol clients was 20.
The facility's calculation is as follows: 80/35 = 2.2857 Facility FTE; 20/2.2857 = 8.7500, which equals a client to counselor ratio of 9:1.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To achieve and maintain the appropriate FTE the Program Director will take on a case load immediately. The agency will conduct job fairs and utilize Career-Link Services to identify and hire additional counselors to meet the appropriate FTE. The Program Director will monitor staff turnover weekly to ensure compliance. August 7, 2017 |
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 conducted June 14, 2017 between 1:00 pm and 2:00 pm, it was observed that the facility failed to maintain all structures on the grounds of the facility so as to be free from any danger to health and safety as evidenced by the following:
1)The exterior wood under the eve line of the facility (on the side facing the parking lot) is rotted, missing, falling down and in dis-repair.
2)In the side yard of the facility, behind the wooden fence, the weeds/grass is overgrown. Also, there is a wooden structure towards the back of the yard that was collapsed.
3)In the rear of the facility, where the garbage cans/dumpsters are located, there were roof shingles missing. Additionally, there were roof shingles missing and in disrepair on the side of the facility that faces the parking lot.
4)The outside garbage cans, located in the rear of the facility, were missing lids
The findings were reviewed with facility staff during the licensing inspection process.
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Plan of Correction
The Director of Operations and the Director of Maintenance were informed and made an assessment of all building exterior and grounds maintenance needs. The Director of Operations and the Director of Maintenance have met with three Contractors and are awaiting proposals to make repairs ;i.e. The rotted exterior wood under the eve line of the facility (on the side facing the parking lot), roof shingles missing, additionally, roof shingles missing and in disrepair on the side of the facility that faces the parking lot. Maintenance staff will correct the fence which is falling down and in dis-repair in the side yard of the facility. Landscapers cut the overgrown weeds, grass. Missing lids for outside garbage cans have been replaced. The bathroom floor, which is located at the end of the hallway behind the intake room, will be replaced, the floor under the toilet in the first-floor bathroom will be replaced. The Director of Operations and the Director of Maintenance will conduct monthly inspections to ensure deficiencies do not recur. Considering the extent of repairs 90 days expected to resolve issues. The Director of Maintenance is responsible for ensuring the plan of correction are carried out. September 30, 2017 |
705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on a physical plant inspection conducted June 14, 2017 between 1:00 pm and 2:00 pm, it was observed that the facility failed to properly ventilate, as well as maintain the bathrooms in a functional, clean and sanitary manner as evidenced by the following:
1.The bathroom at the end of the first-floor hallway, towards the rear of the kitchen, did not have an operable exhaust fan or window at the time of the inspection.
2.The second-floor bathroom had mold growing on the ceiling of the shower stall
3.The second-floor bathroom had visible water damage at the base of the walls of the showers, which was allowing the walls between the stalls to deteriorate.
4.The caulking in the third-floor bathroom was falling off the sides of the bath tub.
5.There were several cracked, chipped, broken and loose tiles located in the first-floor bathroom, which was located at the end of the hallway behind the intake room
6.The floor under the toilet in the first-floor bathroom was soft, loose, and sunken down.
The findings were reviewed with facility staff during the licensing inspection process.
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Plan of Correction
The Director of Operations and the Director of Maintenance were informed and made an assessment of all maintenance needs. The bathroom at the end of the first-floor hallway, towards the rear of the kitchen, will have an operable exhaust fan and window installed, the second-floor bathroom mold growing on the ceiling of the shower stall will be removed, the second-floor bathrooms water damage at the base of the walls of the showers, which was allowing the walls between the stalls to deteriorate will be repaired, the caulking in the third-floor bathroom falling off the sides of the bath tub will be replaced, the cracked, chipped, broken and loose tiles located in the first-floor bathroom, which was located at the end of the hallway behind the intake room will be replaced, the floor under the toilet in the first-floor bathroom will be replaced. Maintenance personnel will make the necessary repairs. House Management Staff will supervise daily and weekly cleaning by residents. Monthly scheduled maintenance inspections will be conducted by the maintenance department under the supervision of the Director of Operations and Director of Maintenance to ensure the corrective action is implemented and the deficiency does not recur. The facility will be in full compliance by July 30, 2017. |
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 conducted June 14, 2017 between 1:00 pm and 2:00 pm, it was observed that the basement freezer had a compressor that was frozen over and an interior temperature of 30 degrees Fahrenheit at the time of the inspection.
The findings were reviewed with facility staff during the licensing inspection process
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Plan of Correction
Food Services Director was informed and made an assessment of the freezer and compressor. Food services has contacted a service provider to correct compressor issues. Each house manager shift will check the freezer temperature and report to the Program Director any temperature above freezing. Each house manager shift will check the freezer compressor for signs of icing and report to the Program Director. Regularly scheduled maintenance inspections will be conducted by the maintenance department under the supervision of the Food Services Director to ensure the corrective action is implemented and the deficiency does not recur. July 30, 2017 |
705.9 (1) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(1) Be free of rodent and insect infestation.
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Observations
Based on a physical plant inspection conducted June 14, 2017 between 1:00 pm and 2:00 pm, it was observed that the facility failed to keep the facility free of rodent and insect infestation as evidenced by the following:
1.Under the kitchen stove, there were many dead cockroaches trapped on several bug traps.
2.In the basement by the water pump, there were several large dead cockroaches laying on the floor.
3.In the basement by the furnace, there was evidence of mouse droppings.
The findings were reviewed with facility staff during the licensing inspection process
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Plan of Correction
The Director of Operations and the Director of Maintenance were informed and made an assessment of pest control needs. Ehrlich has contacted and will intensify services at this location from once per month to twice per month. A general house clean-up took place the evening of Wednesday, June 14, 2017. Particular attention was paid to under the kitchen stove, in the basement by the water pump, and in the basement by the furnace. Daily inspections by the facility house manager staff will be monitored by Program Director. Monthly inspections will be conducted by the maintenance department under the supervision of the Director of Operations and Director of Maintenance to ensure the corrective action is implemented and the deficiency does not recur. July 30, 2017 |
705.10 (a) (1) (v) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
Based on a physical plant inspection conducted June 14, 2017 between 1:00 pm and 2:00 pm, the facility failed to light the exit sign that was located outside the counselors' offices in the basement.
The findings were reviewed with facility staff during the licensing inspection process
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Plan of Correction
Maintenance Director was informed and made an assessment of the exit sign that was located outside the counselors' offices in the basement. Assigned maintenance personnel assigned to the facility will correct the issue. Regularly scheduled maintenance inspections will be conducted by the maintenance department under the supervision of the Maintenance Director to ensure the corrective action is implemented and the deficiency does not recur. July 30, 2017 |
709.28 (c) (2) 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. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of seven client records, the facility failed to document the specific information to be released on an informed and voluntary consent to release information form to the urinalysis lab that client #1 signed on 3/18/16.
Client #1 was admitted on 3/18/16 and discharged 6/20/16.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
An in-service facilitated by the Program Director occurred on 6/16/17 to address Confidentiality. Ongoing training will be provided by the Gaudenzia Training Institute. To ensure compliance Program Director will audit open charts bi-weekly to ensure documentation of the name of the person, and/or organization to which disclosure is being made, and documentation of the specific information to be released, specific to the issue raised in the deficiency. Charts will be monitored through our Continues Quality Improvement Program. The facility will be in full compliance by July 30, 2017. The Program Director will ensure compliance. |