Observations
Based on observations during the physical plant inspection, the facility failed to ensure that there were no heaters that were not permanently mounted or installed in the facility.
The findings include:
A physical plant inspection was conducted on May 9, 2014. It was observed during the inspection that the facility had space heaters in the following areas and at the corresponding times:
1) The medication room on the first floor at approximately 10:02 A.M.
2) The nurse's office on the first floor at approximately 10:03 A.M.
3) The house manager's office on the first floor at approximately 10:04 A.M.
The findings were confirmed during an interview with the facility director on May 9, 2014 at approximately 10:05 A.M.
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Plan of Correction
Heaters in question have been removed; facility director will co-ordinate with Central Regional Office of Gaudenzia to address heating issues by appropriate means. |
Observations
Based on a review of client records, the facility failed to document follow-up information in three of four client records reviewed.
The findings include:
Four client records requiring documentation of follow-up information were reviewed on May 9, 2014. The facility failed to document follow-up information in client records # 6, 8 and 9.
Client # 6 was admitted October 27, 2013 and discharged November 26, 2013. The follow-up information was due December 26, 2013. However, client record # 6 did not include documentation of follow-up information as of May 9, 2014.
Client # 8 was admitted December 24, 2013 and discharged January 24, 2014. The follow-up information was due February 23, 2014. However, client record # 8 did not include documentation of follow-up information as of May 9, 2014.
Client # 9 was admitted February 23, 2014 and discharged March 19, 2014. The follow-up information was due April 18, 2014. However, client record # 9 did not include documentation of follow-up information as of May 9, 2014.
The findings were confirmed during an interview with the facility director and clinical supervisor on May 9, 2014 at approximately 3:00 P.M.
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Plan of Correction
Process has been designed and put in place by which Case Manager will complete all follow up calls within seven days of client discarge, to include clients who have been referred from Common Ground to further, inpatient treatment. Facility director will follow up to insure that this process is being followed. |