INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on November 2, 2009 through November 3, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia DRC, Inc. 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 and a plan of correction is due on December 6, 2009.
|
Plan of Correction
|
709.32(c)(3) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(3) Inspection of storage areas.
|
Observations
Based on a review of administrative materials and staff interview, the facility failed to follow their written policy to inspect all drug storage areas on a monthly basis.
The findings include:
Based on a review of administrative materials and staff interview on November 3, 2009, the facility was required to document monthly inspections of the drug storage areas. There was no documentation of the drug storage area on the first floor. The nurse informed the licensing specialist that monthly inspections of the drug storage areas are conducted for the drug storage areas on the units where the clients reside, but not for the drug storage area in the medical department on the first floor.
|
Plan of Correction
Per the written policy, the Medical Department will follow the written policy and inspect all drug storage areas on a monthly basis and the medication drug storage form will serve as verification. The form will be completed on a monthly basis and signed by the Medical Administrator inspecting the areas and kept in a binder.
The Medical Administrator will monitor the completion, compliance and timeliness of the form monthly via the Continuous Quality Improvement (CQI) process.
Persons Responsible: Medical Administrator, Inpatient Program Director
Timeframe for Completion: November 30, 2009.
|
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
|
Observations
Based on a review of personnel records and staff interview, the facility failed to document fire extinguisher training within seven days of the date of hire in one of five personnel records.
The findings include:
Five personnel records were reviewed on November 2, 2009. Documentation of fire extinguisher training within seven days of the date of hire was required in five personnel records. Fire extinguisher training in personnel record #3 was due by March 23, 2009. Fire extinguisher training in personnel record #3 was not documented until April 27, 2009.
|
Plan of Correction
New hires will be instructed in the use of the fire extinguisher within seven days from the date of employment. This will be documented on the Orientation Checklist.
The Human Resources Director will monitor the completion, compliance and timeliness of this instruction via the Continuous Quality Improvement (CQI) process.
Persons Responsible: Human Resources Director, Inpatient Program Director
Timeframe for Completion: December 1, 2009.
|
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
|
Observations
Based on a review of client records and administrative materials, the facility failed to document physical examinations in two of four records.
The findings include:
Five client records were reviewed on November 3, 2009. Physical examinations were required in four client records. A physical examination was not documented in client records #3 and 4. According to the facility's policy, physical examinations are required to be completed within one week of the client's admission. The physical examination was due to be completed by 4/14/09 in client record #3; no physical examination was documented in client record #3 as of November 3, 2009. The physical examination was due to be completed by 6/15/09 in client record #4; no physical examination was documented in client record #4 as of November 3, 2009.
|
Plan of Correction
All physical examinations will be completed. The Medical Administrator will turn the completed physicals over to the Program Director for inclusion in the client record.
The Medical Administrator will monitor the completion, compliance and timeliness of the physicals monthly via the Continuous Quality Improvement (CQI) process.
Persons Responsible: Medical Administrator, Inpatient Program Director
Timeframe for Completion: November 30, 2009.
|
709.52(a)(2) LICENSURE Tx type & frequency
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
|
Observations
Based on a review of client records, the facility failed to document the frequency of treatment and rehabilitation services in two of four records.
The findings include:
Five client records were reviewed on November 3, 2009. Four client records were required to have the frequency of treatment and rehabilitation services documented on the treatment plan. The frequency of treatment and rehabilitation services was not documented on the treatment plan in client records #1 and 2.
|
Plan of Correction
A record-keeping training to include a review of treatment plan standards will be facilitated on January 12, 2010 to ensure that all staff document the type and frequency of treatment and rehabilitation services on the treatment plan per DOH Policy 709.52 (a)(2).
All treatment plan documentation and compliance timeframes will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings and monitored for three (3) months to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible: Division Director, Inpatient Program Director.
Timeframe for Completion: January 31, 2010
|
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
|
Observations
Based on a review of client records, the facility failed to document a treatment plan update in one of three records.
The findings include:
Five client records were reviewed on November 3, 2009. A treatment plan update was required in three client records. A treatment plan update was due to be completed by 10/23/09 in client record #1. A treatment plan update was not documented in client record #1 as of November 3, 2009. The treatment plan update in client record #2 only documented progress on one of the three goals documented for the client. There was no progress documented for goals #2 and 3 in the treatment plan update for client record #2.
|
Plan of Correction
A record-keeping training to include a review of the treatment planning systems will be facilitated to ensure that all staff document Treatment Plan Updates at least every thirty (30) days as required by the Division of Drug and Alcohol Licensure.
All treatment plan update documentation and compliance timeframes will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings and monitored for three (3) months to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible: Division Director, IP Program Director
Timeframe for Completion: January 31, 2010.
|
709.53(a)(2) LICENSURE Medication records
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:
(2) Medication records.
|
Observations
Based on a review of client records, the facility failed to document complete medication records in ome of two records.
The findings include:
Five client records were reviewed on November 3, 2009. Medication records were required in two client records. Documentation in client record #1 showed that the client was on Bactrim, Prozac, Vistoral and Triliptol. There was no documentation of the dosages taken for the Prozac, Vistoral and Triliptol.
|
Plan of Correction
The Program Director will ensure that all client records provide a complete medication record documenting the type of medication, dosage, and frequency of use where applicable.
All medication, dosage, and frequency documentation will be reviewed during monthly Continuous Quality Improvement (CQI) meetings and intensively monitored for three (3) months to ensure compliance, completion, and timelines.
Persons Responsible: Medical Administrator, Inpatient Program Director
Timeframe for Completion: November 30, 2009
|