INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 29, 2007 through November 30, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia, Inc. WINNER Co-Occurring Women & Children Program 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 24, 2007.
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Plan of Correction
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705.7 (b) (3) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(3) Clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
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Observations
Based on a review of the physical plant, the facility failed to store all eating and drinking utensils in a clean enclosed area.
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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(a) LICENSURE Project Director
709.23. Project director.
(a) The project director shall prepare and annually update a written manual delineating project policies and procedures.
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Observations
Based on a review of the policy and procedure manuals, the facility failed to prepare and update a manual delineating project policies and procedures that were consistent with the practices of the facility and of the project. The facility presented two (paper) policy and procedure manuals and one electronic manual. The policies and procedures for client rights, medication administration and follow up information were different and inconsistent in the three manuals presented for review.
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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. |
709.26(b)(4) LICENSURE Personnel Management
709.26. Personnel management.
(b) The governing body shall adopt a written policy to implement and coordinate personnel management which includes, but is not limited to:
(4) The implementation of Federal, State and local statutes concerning fair employment practices.
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Observations
Based on a review of administrative documentation, the facility failed to document the implementation of Federal, State and local statutes concerning fair employment practices.
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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(b) LICENSURE Medication Control
709.32. Medication control.
(b) Verbal medication orders may be accepted but shall be put in writing and signed within 24 hours thereafter by the prescribing physician.
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Observations
Based on a review of medical records, the facility failed to document that verbal orders were signed within 24 hours by the prescribing physician in two of two medical records reviewed, #1 and 2. The date of the physician's signature was not documented on verbal orders.
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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)(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.
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Observations
Based on a review of policy and procedure and the medication inspection record, the facility failed to document inspections of the medication storage area as per the project's policy from August 2007 through October 2007. The policy stated that inspection would be documented monthly. There were no inspections documented for the months of August, September and October 2007.
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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)(6) 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:
(6) Inventories.
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Observations
Based on a review of the policy and procedure manual and the medication inventory record, the facility failed to document an inventory of prescription medication samples the facility maintains that were provided by the facility's physician. The policy indicated that inventories were to be documented monthly. No inventories of prescription medication samples were documented.
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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. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a complete psychosocial evaluation in four of four client records reviewed, #1, 2, 3 and 4. Psychosocial evaluations did not include an assessment of the client's assets/strengths, support systems and coping mechanisms.
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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)(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.
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Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services in four of four client records reviewed, # 1, 2, 3 and 4.
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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(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.
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Observations
Based on a review of client records, the facility failed to document as assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan in two of three client records reviewed, #1 and 3.
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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. |