INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 20, 2008 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 December 18, 2008.
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Plan of Correction
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709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records the facility failed to document an informed consent in three of three client records.
The findings include:
Three client records were reviewed on November 20, 2008. The releases of information contained both "release to" and "receive from" sections. The "receive from" section of the consent to release information form contains language that detracts from an informed consent in client records # 1, 2 and 3.
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Plan of Correction
New releases of information are being implemented in all programs by the directors. Division Director - will train,implement,monitor new relase 12/18/2008 |
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 clinical documentation, the facility failed to document monthly inspections by the facility nurse in accordance with their policy and procedures manual.
The findings include:
The facility failed to document monthly inspections, by the facility nurse, of medication areas for the months of April, May, June and August 2008.
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Plan of Correction
Facility nurse will inspect each month and inspections will be kept at the facility along with a copy given to the Division Director, at the main facility for their records along with the reports being monitored in our monthly QI process - 12/18/2008 |