INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 27, 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 Inc. Vantage 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) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
Based on a review of seven client records, the facility failed to document if the clients received their medications or why they did not receive their medication in the Medication Administration Record (MAR) or Missed Medication Log in all seven client records.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
All prescribed medications, including those ordered prn will be correctly documented on the MAR. This will include indication of instances when the client refused the prn medication.
This will be addressed by the Nurse Manager via an in-service training during the upcoming on 6/17/21.
The Nurse will conduct weekly reviews of the MARs in order to ensure accuracy. The Clinical Supervisor and/or Program Director will conduct monthly reviews. Any concerns will be reported to the Director to be addressed.
The Quality Assurance team will conduct quarterly reviews and the Compliance team will conduct at least annual reviews of the plan of correction to ensure compliance.
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709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of seven client records, the facility failed to ensure that all work done by the client at the project is an integral part of his treatment and rehabilitation plan in all seven client records.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Intake specialist, during the intake assessment, will list "work as treatment" on the initial treatment plan to reflect that work done by clients is therapeutic in nature and documented as an integral part of treatment.
Furthermore, work as treatment and treatment planning will be reviewed by the Clinical Supervisor in an in-service training during the Clinical Team meeting on 6/22/21 to ensure that all clinical staff include work as treatment on all concurrent treatment plan updates.
The clinical supervisor will review treatment plans monthly during monthly CQI audits to ensure that any chores or other work assigned as part of treatment process will be listed as interventions in the treatment plans. Any concerns will be reported to the Director to be addressed.
The Quality Assurance team will conduct quarterly reviews and the Compliance team will conduct at least annual reviews of the plan of correction to ensure compliance.
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