INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on January 10, 2024 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Angels Light Half Way House, LLC was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection, the facility failed to provide either individual paper towels or a mechanical dryer in each bathroom. There were no paper towels, nor a mechanical dryer in the bathroom located in the last room on the right on the third floor.
This finding was reviewed with facility staff during the complaint investigation.
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Plan of Correction
As per regulation 705.6, all restrooms will have at least three rolls of paper towel located in all restrooms. When the client is completing their daily chore in the evening, it will be their responsibility to ensure that one paper towel is located on the sink and two underneath the sink, the soap dispenser is full, and cleaning the wall mirror as part of their chore. The techs, when checking daily chores, will ensure that all restrooms have three rolls of paper towel present, the soap dispenser is filled, and the mirror is cleaned. This was effective as of 1/10/2024. |
709.32 (c) (1) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication, including the documentation of the administration of medication:
(i) By individuals permitted to administer by Pennsylvania law.
(ii) When self administered by the client.
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Observations
Based on staff and client interviews conducted on January 10, 2024, the facility failed to allow clients to self-administer medications. Medications were being administered by individuals not permitted to do so by Pennsylvania law. Non-medical personnel were administering medications to the clients.
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Plan of Correction
As per regulation 709.32(c), clients started to dispense their own medication while the techs observe their medication pass that started immediately on 1/10/2024. Clients are handed their medication card from the tech where they are responsible to dispense their own medication into a medicine cup. The tech will observe that they are taking the correct amount of medication per their prescription and counting the medication in the cup before the client takes their medication. The tech will initial the MARS book once the medication has been taken. |
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 charts, the facility failed to provide a complete client record on an individual which includes information relative to the client's medication records in 3 of 5 charts reviewed.
Client # 3 was admitted July 17, 2023, and discharge September 15, 2023. The medication record was missing documentation as to why medications were not taken as prescribed.
Client # 4 was admitted November 7, 2023, and discharged December 27, 2023. The medication record was missing documentation as to why medications were not taken as prescribed.
Client # 5 was admitted July 20, 2023, and discharged September 3, 2023. The medication record was missing documentation as to why medications were not taken as prescribed.
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Plan of Correction
As per regulation 709.53(a)(2), clients who refuse their medication will be documented on the back of the MARS sheet of why the medication was refused. The lead tech will inform the clinician of why the client refused their medication so they can write a general note in the client's chart. When a client is out of medication, the clinician will write a general note of the plan of correction as to what has been done to fix the medication issue. |