INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November
16 - 18, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Eire Inc. - Crossroads 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 18, 2009.
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Plan of Correction
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705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based on a physical plant tour on November 18, 2009 at 10:00 am, the facility failed to ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
The findings include:
Based on a physical plant tour on November 18, 2009 at 10:00 am, the facility failed to provide an unobstructed exit from bedroom D-1. At the time of the tour, bedroom D-1 had a dresser blocking the doorway, and the door was unable to be completely opened. The director and the maintenance staff moved the dresser during the tour, therefore allowing the door to be opened without obstruction.
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Plan of Correction
During daily inspections of the physical plant, staff will ensure that all doorways and entrances are unobstructed. Staff will also educate clients on the need for keeping furniture where it is and not moving pieces around. This is effective immediately and will be monitored by all supervisors and the Program Director. |
709.53(a)(5) LICENSURE Progress Notes
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:
(5) Progress notes.
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Observations
Based on a review of the client records, the facility failed to document group progress notes in five of the five required records.
The findings include:
Five client records were reviewed on November 18, 2009. Five of the five records were required to have provided documentation of group progress notes. Five of the five records, records #3, 4, 5, 6, and 7, did not include this documentation. When discussed with the facility director on 11-18-09, it was determined that the group progress notes were not completed.
Record #3 was admitted 10-28-09. There are no group progress notes documented.
Record #4 was admitted 9-28-09. There are no group progress notes documented.
Record #5 was admitted 10-9-09. There are no group progress notes documented.
Record #6 was admitted 9-22-09 and discharged on 10-20-09. There are no group progress notes documented.
Record #7 was admitted 7-29-09 and discharged on 9-9-09. There are no group progress notes documented.
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Plan of Correction
A new clinical group feedback sheet was developed on 11/19/09. A training is set up for December 8, 2009 to train all clinical staff on properly completing clinical group notes. The Program Director will administer the training and monitor the content of the group notes on a monthly basis. These will also be reviewed in the monthly UR/QI meetings. |