INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on November 13- 15, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Coatesville Treatment Center 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 December 14, 2007.
|
Plan of Correction
|
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
|
Observations
Based on a review of training records, clinical supervision notes and conversations with the facility director and one clinical supervisor on November 14 and 15, 2007 it was determined that the facility failed to document weekly close supervision and direct observation for three of the five counselor assistants. A review of the training records, clinical supervision notes and conversations with the facility director and one clinical supervisor revealed that for employees #8, 9 and 10 the facility failed to document that the employees received the appropriate, weekly clinical supervision per the required supervised periods set forth in 28 Pa. Code Chapter 704.
|
Plan of Correction
The counselor assistants are supervised on a weekly basis by the clinical supervisor. This is documented by the clinical supervisor in a supervision note in the supervision manual. Direct observations are done for one hour one time per week by the clinical supervisor or a designated counselor. These are documented in a supervision note in the supervision manual by the clinical supervisor or the counselor completing the direct observation. The clinic director will review this manual bi-weekly for compliance. The clinic director will conduct a meeting with the clinical supervisors regarding supervision and direct observation expectations by January 4, 2008. |
704.10 LICENSURE Counselor Asst Promotion
704.10. Promotion of counselor assistant.
(a) A counselor assistant who satisfactorily completes one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) may be promoted to the position of counselor.
(b) A counselor assistant shall document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year.
(c) A counselor assistant shall meet the requirements for counselor within 5 years of employment. A counselor assistant who has accumulated less than 7,500 hours of employment during the first 5 years of employment will have 2 additional years to meet the requirements for counselor.
(d) A counselor assistant who cannot meet the time requirements in subsection (c) may submit to the Department a written petition requesting an exception. The petition shall describe the circumstances that make compliance with subsection (c) impracticable and shall be approved by both the clinical supervisor or lead counselor and the project director. Granting of the petition will be within the discretion of the Department.
|
Observations
Based on a review of training records, clinical supervision notes and conversations with the facility director and one clinical supervisor on November 14 and 15, 2007, it was determined that the facility failed to assure that two of the five counselor assistants documented to the facility director that they were working toward achieving qualifications for counselor status. A review of the training records, clinical supervision notes and conversations with the facility director and one clinical supervisor revealed that employees #5 and 8 failed to document to the facility director that they were working toward counselor status for the calendar year of 2006.
|
Plan of Correction
One counselor assistant has resigned effective 11/30/07. The clinical supervisor of the remaining counselor assistant and all future counselor assistants will require each counselor assistant to report progress towards counselor status in one on one supervision on a quarterly basis. This will be documented in the supervision manual. The clinic director will review the manual quarterly for compliance. The clinic director will request a written letter upon the counselor assistant's annual performance evaluation documenting progress towards counselor status. This will be required of future counselor assistants upon their annual performance evaluation.
|
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
|
Observations
Based on a review of employee training records on November 14- 15, 2007 it was determined that the facility failed to assure that each employee received a written individual training plan. A review of ten of ten employee training records, specifically #1, 2, 3, 4, 5, 6, 7, 8, 9 and 10, revealed that the individual training plans only include one subject with no time frame. The individual training plans were not specific to each employees training needs.
|
Plan of Correction
Training plans will be individualized listing the specific required trainings as well as other topics specific to each employee's needs with time frames. They will be completed by the supervisor and counselor at the end of December each year. The supervisor will recommend trainings in problem areas identified throughout supervision. The supervisor will question the employee about strengths and weaknesses in discussing training recommendations for the upcoming year. The Clinic director will review annually in December to ensure they are specific to the employee's needs. |
704.11(b)(2) & (3) LICENSURE Basis of Training Plan
704.11. Staff development program.
(b) Individual training plan.
(2) This plan shall be based upon an employee's previous education, experience, current job functions and job performance.
(3) Each individual employee shall complete the minimum training hours as listed in subsections (d)-(g). The subject areas in subsections (d)-(g), with the exception of subsection (g), are suggested training areas. They are not mandates. Subject selections shall be based upon needs delineated in the individual's training plan.
|
Observations
Based on a review of employee training records on November 14- 15, 2007 it was determined that the facility failed to assure that each employee received a written individual training plan based upon an employee's needs. A review of ten of ten employee training records, specifically #1, 2, 3, 4, 5, 6, 7, 8, 9 and 10, revealed that the individual training plans were not specific to each employee's training needs. The individual training plans were not individualized and contained similar training topics for all the employees reviewed.
|
Plan of Correction
Training plans will be individualized listing the specific required trainings as well as other topics specific to each employees needs with time frames. They will be completed by the supervisor one on one at the end of December each year. The supervisor will recommend trainings in problem areas identified throughout supervision. The supervisor will question the employee about strengths and weaknesses in discussing training recommendations for the upcoming year. The Clinic director will review annually in December to ensure they are specific to the employee's needs.
|
704.11(d)(1) LICENSURE Training Req-Proj/Fac Directors
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(1) Subject areas for training shall be selected according to the training plan for each individual.
|
Observations
Based on a review of employee training records on November 14- 15, 2007 it was determined that the facility failed to assure that the subject areas for training shall be selected according to the training plan for each individual. A review of the project directors and facility directors training record revealed that the individual training plans only listed one training subject. The individual training plans were not specific to each employees' training needs.
|
Plan of Correction
Training plans will be individualized listing the specific required trainings as well as other topics specific to each employees needs with time frames. They will be completed by the supervisor one on one at the end of December each year. The supervisor will recommend trainings in problem areas identified throughout supervision. The supervisor will question the employee about strengths and weaknesses in discussing training recommendations for the upcoming year. The clinic director will review annually in December to ensure they are specific to the employee's needs |
704.11(g)(1) LICENSURE Trng Req-Couns Asst
(g) Training requirements for counselor assistants.
(1) Each counselor assistant shall complete at least 40 clock hours of training the first year and 30 clock hours annually thereafter in areas such as:
(i) Pharmacology.
(ii) Confidentiality.
(iii) Client recordkeeping.
(iv) Drug and alcohol assessment.
(v) Basic counseling.
(vi) Treatment planning.
(vii) The disease of addiction.
(viii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Interaction of addiction and mental illness.
(xii) Cultural awareness.
(xiii) Sexual harassment.
(xiv) Developmental psychology.
(xv) Relapse prevention.
(h) Training hours. Training hours are not cumulative from one personnel classification to another.
|
Observations
Based on review of employee training records on November 14-15, 2007 it was determined that the facility failed to assure that counselor assistants received the required amount of training hours for the 2006 training year. A review of counselor assistants' training records revealed that in one of five records, specifically #5, the counselor assistant completed only 17.5 hours out of 30 required hours of annual training for the training year 2006.
|
Plan of Correction
When a new training plan is developed the clinical supervisors will calculate the training hours and review time frames for trainings for all counselors and counselor assistants on a quarterly basis. If the staff have not completed projected hours the clinical supervisors will set up a schedule in which to complete them and will further monitor training hours in supervision twice a month. The clinic director will review training binders quarterly for training progress/compliance.
|
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
|
Observations
Based on a review of personnel records and training records on November 14- 15, 2007 it was determined that the facility failed to assure that staff were instructed in the use of a fire extinguisher upon staff employment. A review of five of eight personnel and training records, specifically #2, 3, 4, 6 and 7, revealed that staff did not receive the instruction on the use of the fire extinguishers within seven days of employment.
|
Plan of Correction
Effective immediately all new staff to receive instruction on use of fire extinguishers within seven days of employment. All staff will receive this training annually. Certificates to be given to all employees and will be placed in the training binders. The clinic director will monitor when new hires begin employment and on a quarterly basis in the health and safety meetings. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
|
Observations
Based on a review of the fire drill log and conversation with one staff member it was determined that the facility failed to conduct unannounced fire drills at least once a month. A review of the fire drill log and conversation with a staff member on November 15, 2007 revealed that the facility failed to conduct monthly fire drills for July and August 2007.
|
Plan of Correction
Effective immediately, Fire drills to be conducted monthly. The fire drill log will be reviewed on a monthly basis by the clinic director to ensure compliance. |
705.28 (d) (2) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(2) Conduct fire drills during normal staffing conditions.
|
Observations
Based on a review of the fire drill log and conversation with one staff member it was determined that the facility failed to conduct unannounced fire drills during normal staffing conditions. A review of the fire drill log and conversation with a staff member on November 15, 2007 revealed that the facility failed to conduct unannounced fire drills during normal staffing conditions during the months of July, August and September 2007.
|
Plan of Correction
Effective immediately, Fire drills to be conducted monthly. The clinic director will meet with the health and safety officer on a monthly basis to review the fire drill log as well as the hours in which fire drills are conducted. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
|
Observations
Based on a review of personnel records and training records on November 14- 15, 2007 it was determined that the facility failed to assure that staff were trained to perform assigned tasks during emergencies upon staff employment. A review of two of eight personnel and training records, specifically #2 and 3, revealed that staff did not receive training to perform assigned tasks during emergencies within seven days of employment.
|
Plan of Correction
Effective immediately, Disaster preparedness training with new employees will occur within seven days of employment. This includes all types of emergency drills as well as procedures to follow. This training will be facilitated by the health and safety officer annually for all employees. Certificates will be given to all employees when this training is completed. The clinic director will monitor when new hires begin employment and on a quarterly basis in the health and safety meetings. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
|
Observations
Based on a review of the project's policies and procedures manual and client records on November 14- 15, 2007 it was determined that the facility failed to document a drug and alcohol history that included lengths and patterns related to the progressions of use within the timeframe established in the policy manual. A review of seven client records revealed that in two of those client records, specifically #5 and 9, the drug and alcohol history was completed more than 30 days from the admission date as required by the project's policy. In addition, in one of seven client records reviewed, specifically #3, the counselor failed to review and update the personal history when the client was readmitted on April 26, 2007.
|
Plan of Correction
New patients are assigned a counselor immediately after the second portion of the admission is completed. The clinical supervisor will then place a note in the computer to see the assigned counselor. If the patient has not seen the assigned counselor by the 3rd day of dosing his/her dose will be held to meet with the counselor and clinical supervisor to schedule the first appointment. If the patient does not show up for the first scheduled appointment his/her dose will be held to meet with his/her counselor and the clinical supervisor to complete the appointment at that time or within the next day. The dose will be held for the appointment and the appointment will be completed prior to dosing.
A training will be conducted by the clinical supervisors in January 31, 2008 to address psychosocial history time frames as well as writing the drug and alcohol history. The clinical supervisors will review new patient charts on a weekly basis to ensure compliance.
|
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
|
Observations
Based on a review of the project's policies and procedures manual and client records on November 14- 15, 2007 it was determined that the facility failed to document personal histories within the timeframe established in the policy manual. A review of two of seven client records, specifically #5 and 9, revealed that the personal history was completed more than 30 days from the date of admission as required by the project's policy. In addition, in one of seven client records reviewed, specifically #3, the counselor failed to review and update the personal history when the client was readmitted on April 26, 2007.
|
Plan of Correction
New patients are assigned a counselor after the second portion of the admission is completed. The clinical supervisor will then place a note in the computer to see the assigned counselor. If the patient has not seen the assigned counselor by the 3rd day of dosing his/her dose will be held to meet with the counselor and clinical supervisor to schedule the first appointment. If the patient does not show up for the first scheduled appointment his/her dose will be held to meet with his/her counselor and the clinical supervisor to complete the appointment at that time or within the next day. The dose will be held for the appointment and the appointment will be completed prior to dosing.
A training will be conducted by the clinical supervisors in January 2008 to address psychosocial history time frames as well as writing the drug and alcohol history. The clinical supervisors will review new patient charts on a weekly basis to ensure compliance
|
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of the project's policies and procedures manual and client records on November 14- 15, 2007 it was determined that the facility failed to document psychosocial evaluations within the timeframe established in the policy manual. In addition, the facility failed to document a psychosocial evaluation that was clinically evaluative. A review of seven client records revealed that in two of those client records, specifically #5 and 9, the psychosocial evaluation was completed more than 30 days from the date of admission which is required by the project's policy. In one of seven client records reviewed, specifically #3, the counselor failed to complete a psychosocial evaluation when the client was readmitted on April 26, 2007. Lastly, in two client records, specifically #1 and 7, the counselor failed to document the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, client's attitude toward treatment and overall impressions based on the clinician's analysis of the collected historical information.
|
Plan of Correction
A training will be conducted in January 2008 by the clinical supervisors to discuss time frames for psychosocial histories and interpretive summaries as well as how they need to written. Examples to be given to all counselors for a resource and reviewed with all counselors for clarity. Clinical supervisors to review new patient charts on a weekly basis to ensure compliance. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
|
Observations
Based on a review of the project's policies and procedures manual and client records on November 14- 15, 2007 it was determined that the facility failed to consistently document preliminary treatment plans. A review of seven client records revealed that in two of those client records, specifically #1 and 3, the preliminary treatment plan was missing. According to the project's policy and procedures manual the preliminary treatment plan is to be completed during the admission process.
|
Plan of Correction
Preliminary treatment plans will be completed at admission by the admission counselor. The clinical supervisors will review new patient charts on a daily basis to ensure compliance. All admissions counselors will be informed of the protocol for preliminary treatment plans after the weekly staff meeting by January 2, 2008. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
|
Observations
Based on a review of the project's policies and procedures manual and client records on November 14-15, 2007 it was determined that the facility failed to complete individualized treatment and rehabilitation plans per the project's policy. A review of the project's policies and procedures manual indicated that an individual treatment and rehabilitation plan shall be developed with each client within 30 days of the client's admission. A review of three of eight client records, specifically #5, 7 and 9, revealed that the individual treatment and rehabilitation plan was completed more than 30 days after the client's admission to the facility.
|
Plan of Correction
Individual treatment plans will be developed for all patients within 30 days of admission. A treatment plan writing training will be held in January 2008 by the clinical supervisors. Resources to be given to all counselors. New patient charts to be reviewed by the clinical supervisors on a weekly basis to monitor compliance with initial paperwork: Preliminary and individual treatment plans, Psychosocial history and interpretive summaries.
|
709.92(a)(1) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(1) Short and long-term goals for treatment as formulated by both staff and client.
|
Observations
Based on a review of the project's policies and procedures manual and client records on November 14-15, 2007 it was determined that the facility failed to complete individualized treatment and rehabilitation plans per the project's policy. A review of the project's policies and procedures manual indicated that an individual treatment and rehabilitation plan shall include short and long-term treatment goals that will be developed by both the clinician and the client. A review of eight client records demonstrated that in four of those client records, specifically #1, 3, 7, and 11, the individual treatment and rehabilitation plan failed to include short and long-term goals specific to the client. The short and long-term goals were standardized with the main focus of stabilizing the client on methadone and keeping a "$0" balance with the facility.
|
Plan of Correction
Individual treatment plans will be developed for all patients. A treatment plan writing training will be held in January 2008 by the clinical supervisors. Resources to be given to all counselors. New patient charts to be reviewed by the clinical supervisors on a weekly basis to monitor compliance with initial paperwork: Preliminary and individual treatment plans, Psychosocial history and interpretive summaries.
|
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
|
Observations
Based on a review of client records on November 14- 15, 2007 it was determined that the facility failed to assure that counseling services were provided according to the individual treatment and rehabilitation plan. A review of six of six client records, specifically #1, 3, 5, 7, 9 and 11, revealed that treatment services were not provided in accordance with the individual treatment and rehabilitation plan. In client record #5, the client "no showed" for 12 appointments before a clinical intervention was conducted in order to get the client to comply with the individual treatment and rehabilitation plan. The clinician failed to document why the client continued to receive methadone doses when she failed to show up for scheduled individual treatment sessions.
|
Plan of Correction
New patients are assigned a counselor after the second portion of the admission is completed. The clinical supervisor will then place a note in the computer to see the assigned counselor. If the patient has not seen the assigned counselor by the 3rd day of dosing his/her dose will be held to meet with the counselor and clinical supervisor to schedule the first appointment. If the patient does not show up for the first scheduled appointment his/her dose will be held to meet with his/her counselor and the clinical supervisor to complete the appointment at that time or within the next day. The dose will be held for the appointment and the appointment will be completed prior to dosing. All staff were notified of this procedure in an email sent by the clinic director on 12/28/07. The clnical supervisors will further address this procedure in one on one supervision. |
709.92(d) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
|
Observations
Based on a review of client records on November 14- 15, 2007 it was determined that the facility failed to assure that counseling services were provided on a regular and scheduled basis. A review of six of six client records, specifically #1, 3, 5, 7, 9 and 11, revealed that treatment services were not provided on a regular and scheduled basis. In addition, in client record #5, the client "no showed" for 12 appointments before a clinical intervention was conducted in order to get the client to comply with the individual treatment and rehabilitation plan. The clinician failed to document why the client continued to receive methadone doses when she failed to show up for scheduled individual treatment sessions.
|
Plan of Correction
New patients are assigned a counselor after the second portion of the admission is completed. The clinical supervisor will then place a note in the computer to see the assigned counselor. If the patient has not seen the assigned counselor by the 3rd day of dosing his/her dose will be held to meet with the counselor and clinical supervisor to schedule the first appointment. If the patient does not show up for the first scheduled appointment his/her dose will be held to meet with his/her counselor and the clinical supervisor to complete the appointment at that time or within the next day. The dose will be held for the appointment and the appointment will be completed prior to dosing. All staff were notified of this procedure in an email from the clinic director on 12/28/07 listing the procedure. The clinical supervisors will further address the procedure in one on one supervision. All no shows for appointments as well as meetings with patients and clinical supervisor notification will be documented in the patient record. Chart documentation will be reviewed in one on one supervision by the clinical supervisors twice a month. |
709.93(a)(5) LICENSURE Client records
709.93. 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:
(5) Progress notes.
|
Observations
Based on a review of client records on November 14- 15, 2007 it was determined that the facility failed to document the assessment and plan in the clients' progress notes. A review of three of five client records , specifically #1, 3 and 5, revealed that individual and group progress notes failed to document an assessment that included the clinician's analysis based upon both new and previous information and a plan that is reflective of the direction of treatment.
|
Plan of Correction
A training will be conducted in January 2008 by the clinical supervisors to address writing DAP notes with examples of DAP notes to be utilized. The clinical supervisors will monitor in one on one supervision twice a month for active charts and weekly in new patient charts. |
709.93(a)(9) LICENSURE Client records
709.93. 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:
(9) Aftercare plan, if applicable.
|
Observations
Based on a review of client records on November 14- 15, 2007 it was determined that the facility failed to include future goals with time frames in the aftercare plan. A review of client records, specifically #1 and 3, revealed that the aftercare plan did not include personal goals and objectives based on the client's progress achieved during treatment. In addition, the aftercare plan failed to include time frames for the goals established.
|
Plan of Correction
A discharge/aftercare/transition plan to be implemented beginning in January 2008. This will include the patient's SNAP upon admission and discharge as well as course of treatment, reason for discharge. An aftercare/transition plan is also included with short term and long term goals for the patient as well as time frames. The clinical supervisors will review all discharge charts for compliance. A training will be conducted by the clinical supervisors by January 14, 2008 to review protocol for completing these plans. The aftercare/transition plan is completed when patients are transferred to another program, another level of care, and another component of care at CTC. The discharge summary is completed within one week of discharge. |
709.93(a)(10) LICENSURE Client records
709.93. 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:
(10) Discharge summary.
|
Observations
Based on a review of client records conducted on November 14- 15, 2007 it was determined that the facility failed to document discharge summaries that included information relative to the client's involvement with the project. A review of four of seven client records, specifically #2, 6, 10 and 14, revealed that the discharge summary failed to describe the client's reasons for treatment and response to treatment.
|
Plan of Correction
The clinical supervisors will a conduct a training on writing discharge summaries for all clinical staff by the end of January 2008 and will utilize an example to be given out to all staff. This will include how to document response to treatment, noting progress in recovery, accomplishments as well as lack of progress, limitations in a detailed and cohesive manner. The reason for treatment will reviewed and where this information can be referenced for clarity in the chart. The clinical supervisors will review all discharge summaries to ensure compliance. |
709.94(a) LICENSURE Project management services
709.94. Project management services.
(a) Outpatient projects shall make an effort to adjust the hours of project operations to meet client needs, taking into account other client time commitments such as employment and school schedules.
|
Observations
Based on a review of the project's policies and procedures manual and the physical plant on November 13- 15, 2007 it was determined that the facility failed to adopt one schedule for the hours of project operations. A review of the project's policies and procedures manual on November 13, 2007 indicated that the project's hours of operation for dosing were Monday through Friday from 05:30 AM to 12:30 PM, Saturday from 05:30 AM to 10:30 AM and Sunday from 05:30 AM to 07:30 AM. The project's hours of operations for clinical were Monday through Friday from 05:30 AM to 12:30 AM and Saturday from 05:30 AM to 10:30 AM. A review of the physical plant on November 15, 2007 revealed that the project's hours of operation posted for dosing were Monday through Friday from 05:30 AM to 12:30 PM, Saturday from 05:30 AM to 10:30 AM and closed Sunday. The project's hours of operation posted for clinical were Monday through Friday 05:30 AM to 02:00 PM and closed Sunday.
|
Plan of Correction
As of 12-1-07, Coatesville Treatment Center has posted all current hours of operation for medication and counseling in both buildings. The hours are as follows:
Medication Services
Monday thru Friday 5:30 a.m. to 12:30 p.m.
Saturday 5:30 a.m. to 10:30 a.m.
Sunday 5:30 a.m. to 7:30 a.m.
Counseling Services
Monday thru Friday 5:30 a.m. to 2:00 p.m.
Saturday (Group only) 5:30 a.m. to 10:30 a.m.
|