INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 16, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia - New Destiny 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 July 28, 2010.
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Plan of Correction
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705.10 (a) (1) (v) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
Based on a tour of the physical plant, the facility failed to light interior exits and stairs at all times.
The findings include:
A tour of the facility was conducted on June 16, 2010 at 2:50 PM. During the tour at approximately 3:05 PM, it was found the rear exit off of the second floor was unlit; furthermore the light could be turned off.
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Plan of Correction
All interior exits and stairs will be lit at all times.Light switches will be removed and lights will be hardwired. Blank cover plates will be placed over switch boxes. Program Director will ensure compliance. |
705.11 (2) (ii) LICENSURE Child care.
705.11. Child care.
(2) Interior space. The residential facility shall:
(ii) Maintain security screens or safety locks for all operable windows.
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Observations
Based on a tour of the physical plant, the facility failed to maintain security screens or safety locks on all operable windows.
The findings include:
A tour of the facility was conducted on June 16, 2010 at 2:50 PM. During the tour, it was found that the window in bedroom #5 could be opened to its full capacity; furthermore the screen inside the window was loose and not secured by the window frame.
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Plan of Correction
Safety locks will be maintained on all operable windows within the facility. All screens will also be secured by the window frame. House managers will check the windows daily on house runs and report problems to the program director. The window in room #5 was repaired on 7/18/2010. Regulations regarding 705.11 will be reviewed with all staff. Staff will sign off on the regulation to indicate that they have been informed and understand the regulation.
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709.52(a) LICENSURE Individual TX and REHAB Plan
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:
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Observations
Based on the review of the facility's policies and procedures and the client records, the facility failed to document comprehensive treatment plans after the completion of the clients' biopsychosocial histories and assessments in five out of five inpatient client records.
The findings include:
Gaudenzia's policy, 709.51. b.3, titled Procedure for Intake Documentation of Histories states:
11. Treatment Plan: Based on the psychosocial assessment, the Counselor shall formulate an individualized treatment plan citing a diagnosis, specific problems, goals, action steps to achieve the goals and target dates.
Five client records were reviewed on June 16, 2010. Treatment plans were required in five client records. The treatment plans in client records #1, 2, 3, 4, and 5 were completed before the clients' psychosocial evaluations were documented. Comprehensive treatment plans can not be developed until the client's psychosocial history and psychosocial evaluations are completed.
Client #1's comprehensive treatment plan was completed on 3/16/10 and their psychosocial evaluation was completed on 3/18/10.
Client #2's comprehensive treatment plan was completed on 2/19/10 and their psychosocial evaluation was completed on 2/25/10.
Client #3's comprehensive treatment plan was completed on 1/14/10 and their psychosocial evaluation was completed on 1/28/10.
Client #4's comprehensive treatment plan was completed on 10/26/09 and their psychosocial evaluation was completed on 10/27/10.
Client #5's comprehensive treatment plan was completed on 9/21/09 and their psychosocial evaluation was completed on 9/25/09.
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Plan of Correction
An individual treatment and rehabilitation plan shall be developed with a client following completion of the client's biopsychosocial history. Biopsychosocials and treatment plans will be completed within 72 hours of admission. Clinical staff will meet to review this regulation and will sign indicating they have been informed and understand the regulation. The program director/Clinical Director will review and sign each biopsychocial and initial treatment plan to ensure compliance.
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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 on June 16, 2010 the facility failed to document complete medication records in three out of five inpatient client records.
Findings:
It is the facility's policy to document every time a medication is administered to a client. If the client does not take the medication, the staff must document why the medication was not taken as prescribed. Documentation of missed medications did not occur in three medication records reviewed. During the physical plant inspection the monitor confirmed that they did not know why there was no justification in the medication log records for deviation from the prescription directions.
Client # 1
Drug: Lisinopril
Dates not taken: 4/14.
Drug: Metformin
Dates not taken: 5/20/10 (no pm dose), 5/21/10 (pm), 5/23/10 (pm), 5/27/10 (am), 5/29 (am).
Drug: Albut
Dates not taken: 5/20/10 and 5/22/10
The record did not document why these medications were missed.
Client #2
Drug: Clonidine
Date not taken: 2/3/10, 2/4/10, 2/5/10, 2/6/10, 2/7/10, 2/8/10, 2/9/10, 2/11/10, 2/12/10, 2/13/10,2/14/10, 2/15/10, 2/16/10, 2/17/10, 2/18/10, and 2/19/10 (both am and pm doses were missed on the dates listed above) 3/9/10 (pm), 3/10/10 (pm)
The record did not document why these medications were missed.
Client #3
Drug: Organ-INR
Dates not taken: 2/6/10, 2/7/10, 2/8/10, 2/12/10, 2/13/10,2/14/10, 2/15/10, 2/16/10, 2/17/10, 2/18/10, 2/19/10 and 2/20/10
Drug taken: Zyrtec
Dates not taken: 3/1/10, 3/2/10, 3/3/10, 3/4/10, 3/5/10, 3/6/10, 3/7/10, 3/8/10,and 3/9/10.
The record did not document why these medications were missed.
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Plan of Correction
There will be a complete client record which includes information relative to the client. Medication records will record every time medication is administered to a client and will further document why medication was not taken as prescribed. Facility policy will be reviewed with all staff and staff will indicate they have been informed and understand the policy by signing off on the policy. The program director will review the medication administration log at least once per week to ensure compliance. |