INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 11, 2006 through December 12, 2006 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on January 11, 2007.
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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
The fire drill log did not identify the exit routes used during a fire drill.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.51(b)(6) LICENSURE Psychosocial Evaluation
711.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
The psychosocial evaluations did not assess the client's assets/strengths in five of six client records reviewed, # 1, 2, 3, 4 and 6. The psychosocial evaluations did not assess the client's support systems in five of six client records reviewed, # 1, 2, 4, 5 and 6. The psychosocial evaluations did not assess the client's coping mechanisms in three of six records reviewed, # 2, 5 and 6.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.52(d) LICENSURE Tx Plan Update
711.52. Treatment and rehabilitation services.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regimen is less than 30 days, the treatment and rehabilitation plan review and update shall occur at least every 15 days.
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Observations
Treatment plan updates did not include a review the progress on previously stated goals in six of six client records reviewed, # 1, 2, 3, 4, 5 and 6.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.52(f) LICENSURE Regular/scheduled Services
711.52. Treatment and rehabilitation services.
(f) Counseling shall be provided to a client on a regular and scheduled basis.
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Observations
Counseling services were not provided according to what was prescribed on treatment plans in four of six client records reviewed, # 1, 2, 4 and 6.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.53(c)(2)(ii) LICENSURE Specific Information Disclosed
711.53. Client records.
(c) Confidentiality.
(2) 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:
(ii) The specific information disclosed.
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Observations
The specific information on consent forms to CBH exceeded that allowed by 4 Pa. Code 255.5 in six of six client records reviewed, # 1, 2, 3, 4, 5 and 6.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |