INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 8, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Erie Inc. - Daniel Snow 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 January 5, 2011.
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Plan of Correction
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709.32(c)(2) 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:
(2) Drug storage areas.
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Observations
Based on an inspection of the drug storage area, the facility failed to include only medications in the narcotic lock box area of the drug storage area.
The findings include:
Based on an inspection of the medication cart on December 8, 2010, the facility did not have only medications in the narcotic lock box within the medication cart. There were non-medication items such as a cellular phone and store receipts in this area at the time of the inspection.
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Plan of Correction
The Nurse Manager will conduct monthly medication inspections including the medication storage area monthly and report this in the monthly PI/QI meetings. The Nurse Manager will ensure the pharmacist follows the appointed schedule for medication inspections two times/year. This will be monitored and followed up on by the Clinical Supervisor and Division Director. |
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 procedures and an interview with the facility director, the facility failed to document inspections of the medication storage area, as required by regulation.
The findings include:
The regulation requires an inspection of the medication storage area. On December 6, 2010, policy and procedures were reviewed. Per the agency policy and procedure manual, an inspection of the medication storage area will be completed and documented monthly by the nurse manager and completed and documented twice a year by the pharmacist. Inspections were reviewed for the months of November 2009 to November 2010. The facility failed to document the inspections of the medication storage area for the months of March 2010, April 2010, May 2010, June 2010, July 2010, September 2010, and November 2010.
The facility director confirmed that medication storage area inspections were not documented for the months identified above.
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Plan of Correction
The Nurse Manager will conduct monthly medication inspections including the medication storage area monthly and report this in the monthly PI/QI meetings. The Nurse Manager will ensure the pharmacist follows the appointed schedule for medication inspections two times/year. This will be monitored and followed up on by the Clinical Supervisor and Division Director. |
709.53(a)(3) LICENSURE Records of Service
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:
(3) Record of services provided.
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Observations
Based on the review of client records, the facility failed to document individual counseling sessions on the record of services in two of four client records.
The findings include:
Four client records were reviewed on December 8, 2010. The record of services was required in four client records. The facility did not document the individual counseling sessions on the record of services in client records #1 and #4.
Client #1 was admitted to treatment on 11-3-10. The record of service did not include documentation of the individual counseling sessions provided to the client. Progress notes documented that individual counseling sessions occurred on 11-12-10 and 11-29-10, and an Encounter group occurred on 11-3-10, but there are no entries of these services on the record of service.
Client # 4 was admitted to treatment on 7-19-10, and was discharged from treatment on 9-24-10. The record of service did not document the individual counseling sessions provided to the client. Progress notes documented individual counseling sessions occurred on 7-19-10, 7-23-10, 7-29-10, 8-10-10, 8-26-10, 9-9-10, and 9-23-10, but there are no entries on the record of service.
This was discussed with the facility director on December 8, 2010. The director confirmed the individual sessions were not included on the record of service.
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Plan of Correction
Record of Service will be completed according to policy. This will be monitored by the Clinical Supervisor and overseen by the Division Director through the monthly PI/QI meetings. |