INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 4, 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, 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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704.11(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 four personnel records, the facility failed to ensure that one employee received the minimum of 6 hours of HIV/AIDS training within the regulatory timeframe.
Employee # 4 was hired as a counselor on January 9, 2023 and was due to have the HIV/AIDS training no later than January 9, 2024. However, the communicable disease training was not completed until April 1, 2024.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #4 has completed the required 6-hour HIV/AIDS training on April 1, 2024. Moving forward, all newly hired counselors and counselor assistants will be required to complete the DDAP required trainings within the first 90 days of hire. This will be monitored by the Administrative Assistant and the Program Director via at least monthly reviews of staff training files. Any staff member approaching the 90-day mark will be reminded to schedule the trainings, and any staff member found to have missed the deadline will be required to complete the training immediately. |
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 April 4, 2024, the facility failed to keep the grounds of the facility clean safe and in good repair at all times for the safety and well-being of residents, employees and visitors. The ceiling of Bedroom 305 had a hole and appearance of water damage as evidenced by discoloration.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director has placed an expedited maintenance work order submitted on 4-17-24 to have the roof and ceiling in Bedroom #305 inspected and repaired. The completion date is TBD. Contact was made with the roofing contractors and an assessment was completed on 4-26-24. We are awaiting a completion date from the roofing contractors. Room 305 is currently not being occupied and will not be occupied until all such repairs are completed. The Program Director will schedule annual building inspections with the Maintenance Department to ensure that structural issues are handled in a timely manner. |
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.
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Observations
Based on a physical plant inspection on April 4, 2024, the facility failed to store the cooking utensils in an enclosed area after each usage.
The utensils were in an unenclosed area in the kitchen at 11:10 a.m., between the breakfast and lunch meals.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Program Director submitted a purchase order on 4-17-24, for a 3-drawer cart to store all cooking utensils in the cooking area. The expedited delivery date is TBD. The Support Staff will check the cooking area after every meal to ensure that all utensils have been properly stored. These expectations will be reviewed with all staff in a staff meeting held on 5-2-24, and will be documented via a sign-in sheet. |
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 4, 2024, the facility failed to keep frozen food at or below 0 degrees Fahrenheit, as a freezer in the basement was 15 degrees Fahrenheit.
This is a repeat citation from the May 25, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Food storage will no longer be stored in this freezer. The Program Director submitted a purchase order on 4-17-24, for a new 40-cubic foot deep freezer. Once this is delivered, it will be utilized to store frozen food at or below 0 degrees Fahrenheit. The expected delivery date is 5/17/24. The Support Staff will continue to monitor the temperature of all refrigerators and freezers and record the temperature daily on temperature logs. The Recovery Support Professional Supervisor will monitor log sheets. The Program Director will review these expectations with all staff in a staff meeting on 5-2-24. |
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 May 2023 through February 2024, the facility failed to ensure that fire drill logs included the required information for each fire drill conducted.
The exit route was missing on the fire drill logs from December 16, 2023 and January 25, 2024.
Documentation of whether the smoke detector or fire alarm was operative was missing from the fire drill logs from August 8, 2023 and October 29, 2023.
The amount of time it took for evacuation was missing from the fire drill log from December 15, 2023.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 4/22/24, Fire Drill logs will be monitored and reviewed by the Program Director and the Administrative Assistant after every drill to ensure that all documented fire drills have been completed and documented including all pertinent information. These expectations will be reviewed with all staff in a staff meeting on 5-2-24, and will be documented on a sign in sheet. |
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 one record reviewed.
Client # 7 was admitted on January 18, 2024 and was active at the time of the inspection. The record did not contain a client signed consent to release information form to the funding source; however, the record contained evidence of billing.
This is a repeat citation from the May 25, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Administrative Assistant immediately corrected this error by meeting with client #7 to complete the necessary consent. The consent was review and signed by the client on 4-4-24. Upon admission, consent forms are completed with Administrative Assistant and will be audited by the Program Director during monthly chart reviews. Any issues noted during these audits with be corrected within 48 hours. These expectations will be reviewed with all staff members in a staff meeting on 5-2-24 and will be documented via a sign in sheet. |
709.32 (c) (2) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(2) Drug storage areas including, but not limited to, the secure storage of controlled substances and other abusable drugs in accordance with State and Federal regulations and program requirements.
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Observations
Based on an inspection of the medication storage areas on April 4, 2024 at 3:25 p.m., the facility failed to follow their policy and procedures related to securing drug storing areas. The facility policy states: " Prescribed drugs will be kept in their original containers under secure lock." The medication cabinet contained two separate areas with loose pills, in no storage container.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Recovery Support Professional Supervisor and the Program Director will inspect the medication cart on a daily basis, and document this inspection in a log book to insure that all medications are properly stored. These expectations (including detailed review of the relevant policies and procedures) will be addressed with all staff in a staff meeting on 5-2-24 and will be documented via sign in sheet. |