This report is a result of an onsite follow-up inspection regarding the plans of correction for the May 19, 2009 licensure renewal inspection. The follow-up inspection was conducted on December 1, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Gaudenzia, Inc. West Chester 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 21, 2009.
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Plan of Correction
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Observations
Based on a review of resident medical records and an interview with the facility director and clinical supervisor, the agency failed to document physical examinations within seven days of the admission date.
Findings:
Intake and admission procedures reviewed on May 5, 2009 and May 6, 2009 require resident physical examinations be completed or documented in the resident medical record within seven day of admission. Based on a review of six resident medical records on December 1, 2009 and an interview with the facility director and clinical supervisor on December 1, 2009 at 13:45, the agency failed to document physical examinations in four out of six records within seven days of admission specifically records #1, 2, 5, and 6. The physician also failed to document physician's impressions in three out of six records specifically records # 1, 2, and 3.
Client record # 1: Admitted on September 9, 2009. The physical examination in the medical record was dated October 2, 2009. It was 16 days late. Additionally, the physician failed to document the physician's impressions on the physical exam form.
Client record # 2: Admitted on September 2, 2009. The physical examination in the medical record was dated September 21, 2009. It was 12 days late. Additionally, the physician failed to document the physician's impressions on the physical exam form.
Client record # 5: Admitted July 13, 2009. The physical examination in the medical record was dated October 19, 2009. It was 91 days late.
Client record #6: Admitted July 16, 2009. The physical examination in the medical record was dated July 27, 2009. It was 4 days late.
Interviews with facility staff confirmed the missing documentation.
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Plan of Correction
The Eastern Region Director is aware of the issue regarding physical exam compliance. In order to rectify this problem, he will pursue options to hire a doctor on a consultant basis to ensure that physicals are completed within the required timeframe. Additionally, we will utilize CVIM, an outside agency, to assist in meeting the deadline requirements. The RN/LPN will monitor for compliance which will be reported on monthly to the Eastern Region Director via the Monthly Health Services Report and CQI Report. As of 1/4/10, this corrective action has been implemented. |