INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 4 - 7, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of 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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705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill records, the facility failed to document the use of alternate exits during fire drills.
The front exit was utilized for all fire drills from July 2020 through July 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Fire drills will be conducted utilizing alternate routes to ensure that all routes are tested, and staff are familiar. This will be documented on the fire drill grid.
Division Director held supervision on 10/11/21 with Program Director to discuss the need for alternating exits during fire drills. Program Director will disseminate this information through the internal communication log and in an in-service training will all staff by 11/12/21.
Division Director and Program Director will monitor this process at least monthly through review of internal fire drill grids to ensure compliance.
The Quality Assurance department will conduct at least quarterly program reviews, to include review of fire drill grid, and the Compliance department will conduct a review of all Plans of Correction within 9 months to ensure full implementation.
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709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on a physical plant inspection, review of medication documentation and facility staff interviews on October 5, 2021, the facility failed to document quarterly inspections of the medication storage area from January 2021 through September 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Monthly inspection of all medication storage areas will be completed by the Nurse Manager utilizing a specific checklist to be maintained in the medication area. This will begin by 11/12/21.
The Division Director and Program Director will review documentation of this quarterly inspection to ensure that it is completed in a timely manner, and to address any concerns identified.
The Quality Assurance department will conduct at least quarterly reviews of the program, to include medication storage areas, and the Compliance department will conduct a review of all plans of correction within 9 months to ensure full implementation.
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709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to document the client was notified in writing of the decision to involuntary terminate their treatment at the project and the reasons for termination in two of two client records.
Written termination documentation was not provided for the following clients:
Client # 6 was admitted May 6, 2021 and discharged August 12, 2021.
Client # 7 was admitted July 27, 2021 and discharged September 2, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Division Director held supervision on 10/11/21 with Program Director to discuss the need to notify the client, in writing, when being administratively discharged. Program Director was given a copy of the discharge letter and will review with all staff in an in-service training by 11/12/21.
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709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow-up information within seven days of discharge, per facility policy, in four of four records.
No follow-up information was documented in the following records.
Client # 4 was admitted March 4, 2021 and discharged May 2, 2021.
Client # 5 was admitted April 5, 2021 and discharged July 15, 2021.
Client # 6 was admitted May 6, 2021 and discharged August 12, 2021.
Client # 7 was admitted July 27, 2021 and discharged September 2, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Follow up will be completed and documented for each client identified by 11/12/21.
Follow up will be documented within 7 days for all clients post-discharge.
The Division Director and Program Director will conduct at least monthly audits of discharged charts to ensure that this is completed. Audits will be completed using the standardized audit tool.
The Quality Assurance department will conduct at least quarterly reviews of the program, to include documentation of follow up, and the Compliance department will conduct a review of all plans of correction within 9 months to ensure full implementation.
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