INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 19, 2009 and May 20, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Kindred 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 and a plan of correction is due on June 18, 2009.
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Plan of Correction
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705.10 (a) (1) (iii) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(iii) Maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18-inch drop with a well-secured railing.
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Observations
Based on a physical plant inspection and interview with the facility director, the agency failed to install and maintain three exterior stairways with a handrail.
Findings:
A physical plant tour conducted with clinical director on May 19, 2009 at approximately 14:30 documented three exterior stairways without handrails.
Chapel Building - Exterior steps that lead to the main entrance with eight steps and no handrail.
Exterior Freezer Storage - Nine exterior steps that lead to an underground freezer with no handrail.
Rear exit of Kindred House - Three exterior steps with no handrails installed.
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Plan of Correction
The maitence request has been submitted to faciltate hand rails being placed on all three areas.
Completion date 07/06/2009 |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of client medical records and an interview with the facility director and clinical supervisor the agency failed to document physical examinations within seven day of admission.
Findings:
Intake and admission procedures reviewed on May 5, 2009 and May 6, 2009 require client physical examinations be completed or documented in the client medical record within seven day of admission Based on a review of eight client medical records on May 19, 2009 and May 20, 2009 and an interview with the facility director and clinical supervisor on May 20, 2009 at 14:30 the agency failed to document physical examinations in three of eight records within seven days of admission.
Record review # 1
Admitted on April 28, 2009. Medical record reviewed on May 20, 2009 between the hours of 10:00 and 14:30. No documentation of a physical examination in the medical during the May 20, 2009 review. A request of the medical department and the clinical supervisor also failed to provide documentation of a physical examination for record review
#1
Record review # 3
Admitted on January 30, 2009. Medical record reviewed on May 20, 2009 between the hours of 10:00 and 14:30. The physical examination reviewed in the medical record was dated and signed by the physician on February 5, 2009. The physical examination was timely , however, vital signs and physician impression/diagnosis was not included on the February 5, 2009 physical examination.
Record review # 5
Admitted on August 27, 2008. Discharged February 26, 2009. Medical record reviewed on May 19, 2009 between the hours of 09:30 and 13:00. The physical examination reviewed in the medical record was dated and signed by the physician on September 10, 2008. The physical examination was documented six days late based on the established physical examination documentation procedures.
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Plan of Correction
A letter of agreement will be completed with two local health care facilities it insure complanice with the standards. Program Director will ensure phyicals are in complience via weekly chart audits. Compliance of phyicals will be montiored in CQI. |
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, organizational treatment management procedures, treatment models and a description of the therapeutic community which identifies work therapy assignments, the agency failed to include documentation of work therapy as an integral component of the treatment and rehabilitation plan.
Findings:
Eight of eight client records reviewed on May 19, 2009 and May 20, 2009 required documentation of work therapy in the treatment plan. Eight of eight records failed to document work therapy in the preliminary, comprehensive or treatment plan updates. An interview with the clinical supervisor and facility director on May 20, 2009 between the hours of 14:00 and 14:30 provided addition verification of the lack of work therapy assignments in treatment an rehabilitation plans.
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Plan of Correction
After dicussing problem areas with clients, clinicans will document work therapy assignments based on a statements of the problem to help develop task orientated skills to assist with job enhancement and self-esteem. In-Service training for clinicans 07/06/2009. The Clinical Supervior will conduct weekly audits to esnure compliance and the Director will monitor compliance during supervions with the Clinical Supervisor. Complaince will be monioted in CQI for three months.
Program Supervisor will monitor in weekly clinical meetings.
Completion date 07/10/2009
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