INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 17, 2014 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.
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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 a facility staff to inspect the medication storage area every month starting December 1st, 2014.
Nurse Manager will complete quarterly medication storage area inspections starting January 2015.
Nurse Manager will report her findings from the medication storage area inspection in the QI/UR meeting quarterly beginning in January 2015. |