INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 18,2018 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Re-Entry House was found to be not in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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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
The facility failed to ensure all shifts had staff trained in CPR and First Aid.
The finding:
From May 27, 2018 through June 2, 2018, there was no CPR coverage on the following dates:
Sunday May 27, 2018 from 8pm-8am
Monday May 28, 2018 from 2pm to 4pm
Tuesday May 29, 2018 from 5:30pm-12am
Wednesday May 30, 2018 from 5:30pm-12am
Thursday May 31, 2018 from 5:30pm-12am
Friday June 1, 2018 from 5:30pm -12am
Saturday June 2, 2018 from 8am- 12am
These findings were confirmed with facility director and staff during the licensing process.
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Plan of Correction
All Program Staff have completed their initial or updated CPR/First Aid Certification. Program Director will develop, implement, and monitor an internal tracking form/reports to ensure that all staff receive their initial/updated CPR/First Aid Certification. Program Director will ensure that program is staffed by at least one (1) staff member trained in these skills onsite during the project's hours of operation (24/7). This plan of correction will be completed on 8/1/2018. |
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
The facility failed to ventilate all bathrooms in the facility by window or fan.
The second floor 3rd bathroom did not have a widow or ventilation fan.
These findings were confirmed with facility director and staff during the licensing process.
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Plan of Correction
Facility has obtained an outside contractor to install a ventilation fan in the second floor 3rd bathroom. The ventilation system installation will be completed by September 30, 2018.
As a means of preventing this, and/or any other, deficiencies pertaining bathroom licensing standards, facility House Managers will tour the facility daily to ensure compliance with these standards. Any areas/items out of compliance will be noted and reported to Program Director to be addressed via facility maintenance protocols. Program Director will be the individual responsible for overseeing the implementation of this correction action and will monitor and adjust, as needed. |
709.53(a)(3) LICENSURE Records of Service
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:
(3) Record of services provided.
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Observations
The facility failed to ensure clients had a complete client record. Seven out of seven client records did not have a record of service.
These findings were confirmed with facility director and staff during the licensing process.
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Plan of Correction
Program will complete Record of Services on a weekly basis. Program Director will conduct an in-service training with all Clinical Staff revolving around the completion of record of services. Program Director will ensure that these record of services are completed and inputted into the program's electronic health record system on a monthly basis to ensure all files are in compliance with licensing standards, including, but not limited to, the record of services. This plan of correction will be completed on 8/28/2018. |