INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 27, 2007 through August 28, 2007 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 September 24, 2007.
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Plan of Correction
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709.22(e)(1) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(1) Activities and accomplishments of the preceding year.
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Observations
The facility failed to include activities and accomplishments of the preceding year for the facility in the 2005-2006 annual report.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
The project failed to include time frames and available resources for the 2007-2008 project goals and objectives.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.32(c)(4) 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:
(4) Methods for control and accountability of drugs.
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Observations
Based on a review of client medication administration records, the facility failed to document the administration of client medication. Medication records did not include complete documentation. Several days on the medication records were left blank without any explanation documented explaining why the client did not receive medication as prescribed.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a temperature reading during the physical plant inspection, the facility failed to maintain the hot water temperature at or below 120 degrees Fahrenheit. The hot water registered at 130 degrees Fahrenheit.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.52(a)(3) LICENSURE Support service type
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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to include proposed support services available to the client on the individual treatment plan in six of six client records reviewed, #1, 2, 3, 4, 5 and 6.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.53(a)(9) LICENSURE Aftercare plans
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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to develop individualized aftercare goals based on each client's specific needs in five of six client records reviewed, #5, 6, 7, 8 and 10. The aftercare goals provided for each client were very similar and not based on the needs of each individual client. Specific time frames for the aftercare goals were missing. Time frames used included "daily" and "weekly."
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on a review of the facility's policy and procedure and the follow-up log book, the facility failed to document follow-up information as per policy in six of six client records reviewed, #5, 6, 7, 8, 9 and 10. Follow-up information was not documented in client records #7, 8, 9 and 10 and was documented late in records #5 and 6.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |