INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 16, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Inc. Focus 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 July 15, 2009.
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Plan of Correction
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705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
Based on the physical plant tour, the facility failed to provide slip-resistant surfaces in all bathtubs and showers.
Findings:
The physical plant tour was conducted on June 16, 2009 between 10:00 and 10:30 AM. The facility failed to provide slip-resistant surfaces in the second and third floor bathtub and shower.
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Plan of Correction
Facility purchased slip resistant rubber mats for three (3) bathroom showers and one (1) bathtub. Line staff will replace slip resistant mats every three (3) months. |
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 eight client records, the facility failed to include within the informed and voluntary consent forms the right for clients to verbally revoke the consent. Additionally, the Informed Consent to Transitional Services included general consent language and three client records included blank consent forms signed by the client.
Findings:
Eight client records were reviewed on June 16, 2009. Informed and voluntary consent forms were required in eight client records.
The consent to release information form only indicated that the client could revoke the consent in writing in eight of eight client records, #1, 2, 3, 4, 5, 6, 7 and 8.
The Informed Consent to Transitional Services included general consent language in eight of eight client records, #1, 2, 3, 4, 5, 6, 7 and 8.
Three client records contained a blank consent form signed by the client, #2, 3 and 4.
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Plan of Correction
The informed and voluntary consent forms has been modified to include client's right to verbally revoke consent. In addition, signed blank consent forms have been removed and discarded by Administrative Assistant from client records #: 2, 3 and 4. Program Supervisor will monitor all client files to ensure consent forms are in compliance monthly. |
709.72(a)(3) LICENSURE Medication records
709.72. 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:
(3) Medication records.
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Observations
Based on a review of eight medication records, the facility failed to provide a complete client record on an individual which includes information relative to the client's involvement with the project to include medication records in three of eight client records.
Findings:
Eight client records were reviewed on June 16, 2009. Medication records were required in eight client records. The facility failed to provide a complete client record on an individual which includes information relative to the client's involvement with the project to include medication records in client records #1, 4 and 5.
In client record #1, the facility failed to document the client's missed administration of Zyprexa on 6/6, 6/7 and 6/10/09.
In client record #4, the facility failed to document the client's missed administration of Benztropine on 6/12/09.
In client record #5, the facility failed to document the client's missed administration of Micodrine on 6/9, 6/12 and 6/15/09.
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Plan of Correction
Program Supervisor will monitor medication log records daily to ensure that a complete record on an individual includes all information relative to involvement of project. A new form was established to provide a place for refused medication. Program Supervisor will in-service train staff and monitor staff to ensure that residents take medications as prescribe by doctor. |