INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 16, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Erie Inc. / Community 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.
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Plan of Correction
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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 an interview with the facility director, the facility failed to document inspections of the medication storage area.
The findings include:
Inspections were reviewed for the months of October 2013 to September 2014. The facility failed to document the inspections of the medication storage area for January - March 2014, and July - September 2014.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Program Director will assign facility staff to complete a monthly inspection of the medication storage area and any issues will be reported to the Program Director starting December 1st, 2014.
Agency Nurse Manager will complete quarterly inspections of the medication storage area and will report findings in the QI/UR meeting quarterly starting in January 2015. |
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 the review of client records, the facility failed to document the frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in two of four client records.
The findings included:
Four client records were reviewed on October 16, 2014. Two of the four client records did not document the frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan .
Client #1 - Client was admitted to treatment April 18, 2014, and was discharged on July 17, 2014. An individual treatment and rehabilitation plan was completed on April 30, 2014, but did not document the frequency of treatment and rehabilitation services.
Client #2 - Client was admitted to treatment on July 7, 2014 and was discharged on September 2, 2014. An individual treatment and rehabilitation plan was completed on July 21, 2014, but did not document the frequency of treatment and rehabilitation services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will review client records monthly and check to assure the frequency of treatment and rehabilitative services are documented on the individual treatment plan starting December 2014.
Program Director will report any issues related to frequency of treatment services and rehabilitation services on the treatment plan in the agency monthly QI/UR meeting starting in December 2014. |