INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on July 2, 2024 by staff from the Bureau of Program Operations. Based on the findings of the on-site complaint investigation, Angel's Light Addiction Specialists was found not to be 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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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, the facility failed to remain in good repair at all times for the safety and well-being of residents, employees and visitors.
DDAP staff worked in a counseling office where it was observed that the outlet cover was missing.
This finding was reviewed with facility staff during the investigation process.
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Plan of Correction
ALAS has replaced the missing outlet cover to the electrical socket on 7/3/24 with a brand new electrical outlet covering. The Project Director will complete monthly facility walkthroughs to inspect the physical plant for any repairs needed and will be responsible for submitting the CAP. |
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.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which included an accurate medication record in one of four client records reviews.
Client #3 was admitted on May 24, 2024 and discharged on June 27, 2024. The client was precribed a medication which was to be taken two times a day. Per the Medication Administration Record, the evening dose of the medication stopped on June 12 and the morning dose of the medication was stopped on June 16, 2024. It was reported by facility staff that the client was sent to an outside agency for an alternate medication during this time period; however, there is no documentation in the client record to confirm this was the case.
These findings were reviewed with facility staff during the investigation process.
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Plan of Correction
ALAS Project Director will retrain staff members who observed medication pass on documentation. To prevent reoccurrence, education will include utilization of the backside of the MAR sheet to document med refusals and the tech manager will be responsible for randomly completing MAR audits to ensure compliance etc. Training will be completed by 8/9/24. |