INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 17, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Integrity 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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709.32 (c) (6) LICENSURE Medication control
§ 709.32. Medication control.
(6) Medication errors and drug reactions shall be recorded in the client record. This may be the medical record if a separate medical record is maintained for all clients.
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Observations
Based on a review of client medical records, the facility failed to ensure that missed medication was documented in the medical records in all six applicable client records
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Program Director will ensure that all medication errors reported by the Nurse or staff will be recorded and reported using the proper procedures as follows: The incident will be recorded in the resident's record including notation of the date of missed medication and other applicable information. When appropriate, Gaudenzia will contact the Federal Food and Drug Administration and the manufacturer of the medication in accordance with applicable laws. At no time will the resident's right to confidentiality be violated; the only exceptions noted in 709.28 (e) regarding medical emergencies. An incident report shall be completed by the involved nurse and/or other staff who was involved in the incident and will be reviewed by the Program Director and/ or Clinical supervisor to ensure accuracy. |
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document that all work done by the client at the project is an integral part of his treatment and rehabilitation plan in five of the seven client records reviewed.
Client #1 was admitted on February 10th, 2021 and was still active at the time of the inspection.
Client #3 was admitted on December 14th, 2020 and was still active at the time of the inspection.
Client #4 was admitted on January 28, 2021 and was still active at the time of the inspection.
Client #6 was admitted on October 9, 2020 and was discharged on December 21, 2020.
Client #7 was admitted on August 10, 2020 and was discharged on January 26, 2021.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Program Director will ensure that all daily chores conducted by client is therapeutic in nature and included in all client treatment plans, noting that these chores teach life skills, responsibility, social interaction, and have other therapeutic purposes. The Program Director will ensure treatment plans include information relative to the client's involvement with the project, specifically, work done by clients, and will ensure compliance with this through monthly client chart audits and documentation of audit in a monthly audit report. In addition, the Regional Quality Assurance Manager will conduct quarterly audits to ensure compliance; this audit will be documented in the quarterly CQI report. The compliance department will conduct annual reviews to ensure continued implementation of all action items on the correction action plan. |