INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 11, 2007 to June 13, 2007 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 July 9, 2007.
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Plan of Correction
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704.9(b) LICENSURE Performance evaluation
704.9. Supervision of counselor assistant.
(b) Performance evaluation. The counselor assistant shall be given a written semiannual performance evaluation based upon measurable performance standards. If the individual does not meet the standards at the time of evaluation, the counselor assistant shall remain in this status until the supervised period set forth in subsection (c) is completed and a satisfactory rating is received from the counselor assistant's supervisor.
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Observations
The facility failed to document the 6 month performance evaluation for 1 out of 7 counselor assistants. Staff number 10 did not have a 6 month performance evaluation as required by facility policy and procedure.
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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. |
705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
The facility failed to install an exhaust fan in the small lavatory at the entrance to the large octagon shaped lounge.
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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. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
The facility failed to document fire drills for the months of February and April 2007.
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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. |
709.28(c)(2) 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:
(2) Specific information disclosed.
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Observations
The facility failed to limit information released to the payors of services to the restrictions imposed at 4 Pa. Code subsection 255.5(b). In 3 of 4 client records reviewed (record numbers 1, 2, and 4), the BHSI concurrent review form includes sections for vital signs, substance use history and medications.
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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. |
709.63(a)(6) LICENSURE Aftercare plan
709.63. 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:
(6) Aftercare plans, if applicable.
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Observations
The facility failed to document aftercare plans in closed client records reviewed (Client record #3 and 4).
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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. |
709.53(a)(3) LICENSURE Records of Service
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:
(3) Record of services provided.
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Observations
The facility failed to document individual counseling sessions in the record of services in 3 of 4 client records reviewed (client record numbers 1, 2, and 3).
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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. |