INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 20, 2010 through September 22, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, New Directions Treatment Services 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 October 23, 2010.
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Plan of Correction
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709.30(4) LICENSURE Client Rights
709.30. Client rights.
(4) The client has the right to appeal a decision limiting access to his records to the project director.
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Observations
Based on a review of the facility's policy and procedure manual, as well as a discussion with the facility director, the facility failed to provide a written policy on client rights to include the client's right to appeal a decision limiting access to his records. The findings include:The facility's policy and procedure manual was reviewed on September 20, 2010. A client rights policy was documented within the facility's policy and procedure manual; however this policy did not include documentation stating the client has the right to appeal a decision limiting access to his records. During a discussion, the facility director indicated this must have been missed when writing the policy. The facility director could not locate this portion of the client rights policy.
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Plan of Correction
The following wording has been inserted into the already existing "Client Rights and Responsibilities" document that is given to patients at time of admission:
21. a right to appeal a decision limiting access to his records to the project director.
22. a right to request the correction of inaccurate, irrelevant, outdated or incomplete information from his records.
23. a right to submit rebuttal data or memoranda to his own records.
The patient signs off indicating receipt of of this document and the signoff sheet becomes part of the patient file.
Additionally, all currently active patients admitted prior to this change will be given a memo alerting patients to these rights. Counseling staff have been advised to prepare for questions these rights. Memos will be distributed prior to 11-1-2010 and receipt by all active patients will be verified by the Project Director. |
709.30(5) LICENSURE Client Rights
709.30. Client rights.
(5) The client has the right to request the correction of inaccurate, irrelevant, outdated or incomplete information from his records.
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Observations
Based on a review of the facility's policy and procedure manual, as well as a discussion with the facility director, the facility failed to provide a written policy on client rights to include the client's right to request the correction of inaccurate, irrelevant, outdated or incomplete information from his records. The findings include:The facility's policy and procedure manual was reviewed on September 20, 2010. A client rights policy was documented within the facility's policy and procedure manual; however this policy did not include documentation stating the client has the right to request the correction of inaccurate, irrelevant, outdated or incomplete information from his records. During a discussion, the facility director indicated this must have been missed when writing the policy. The facility director could not locate this portion of the client rights policy.
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Plan of Correction
The following wording has been inserted into the already existing "Client Rights and Responsibilities" document that is given to patients at time of admission:
21. a right to appeal a decision limiting access to his records to the project director.
22. a right to request the correction of inaccurate, irrelevant, outdated or incomplete information from his records.
23. a right to submit rebuttal data or memoranda to his own records.
The patient signs off indicating receipt of of this document and the signoff sheet becomes part of the patient file.
Additionally, all currently active patients admitted prior to this change will be given a memo alerting patients to these rights. Counseling staff have been advised to prepare for questions these rights. Memos will be distributed prior to 11-1-2010 and receipt by all active patients will be verified by the Project Director. |
709.30(6) LICENSURE Client Rights
709.30. Client rights.
(6) The client has the right to submit rebuttal data or memoranda to his own records.
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Observations
Based on a review of the facility's policy and procedure manual, as well as a discussion with the facility director, the facility failed to provide a written policy on client rights to include the client's right to submit rebuttal data or memoranda to his own records. The findings include:The facility's policy and procedure manual was reviewed on September 20, 2010. A client rights policy was documented within the facility's policy and procedure manual; however this policy did not include documentation stating the client has the right to submit rebuttal data or memoranda to his own records. During a discussion, the facility director indicated this must have been missed when writing the policy. The facility director could not locate this portion of the client rights policy.
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Plan of Correction
The following wording has been inserted into the already existing "Client Rights and Responsibilities" document that is given to patients at time of admission:
21. a right to appeal a decision limiting access to his records to the project director.
22. a right to request the correction of inaccurate, irrelevant, outdated or incomplete information from his records.
23. a right to submit rebuttal data or memoranda to his own records.
The patient signs off indicating receipt of of this document and the signoff sheet becomes part of the patient file.
Additionally, all currently active patients admitted prior to this change will be given a memo alerting patients to these rights. Counseling staff have been advised to prepare for questions these rights. Memos will be distributed prior to 11-1-2010 and receipt by all active patients will be verified by the Project Director. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill records and an interview with the facility director, the facility failed to document the use of alternate exit routes.The findings include:Fire drill records were reviewed on September 20, 2010. Fire drills were reviewed for the months of January 2010 through August 2010. The exit route used during the fire drill was not documented on the fire drill record for the following dates: April 30, 2010, May 19, 2010, June 4, 2010, July 8, 2010 and August 30, 2010. During a discussion, the facility director noted that the fire drill record had been changed to a new format and noted this must have accidentally been left off the new format.
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Plan of Correction
The form that is used to document fire drills has been amended to included the capture of this information, i.e. the route of exit from the building. Future drills will reflect the use of various routes in the implementation of the drills. This will be verified by the Project Director. |
709.94(b) LICENSURE Project management services
709.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on a physical plant inspection and discussion with the facility director, the facility failed to display the hours of project operations to the general public. The findings include:A physical plant inspection was conducted on September 22, 2010 at approximately 9:30 AM. During the physical plant inspection, the hours of operation were not displayed to the general public. The facility director noted that the hours are usually posted in the front window, but clients often take them down for their own use. The facility director was unable to locate the hours of operation displayed anywhere.
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Plan of Correction
A sign painting contractor has been contacted by the Projector Director and will be painting the hours of operation and emergency phone number on the door that is used by patients when they enter the building. |
709.94(c) LICENSURE Project management services
709.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based on a physical plant inspection and discussion with the facility director, the facility failed to display a telephone number to the general public for emergency purposes. The findings include:A physical plant inspection was conducted on September 22, 2010 at approximately 9:30 AM. During the physical plant inspection, a telephone number was not displayed to the general public for emergency services. The facility director noted that the telephone number is usually posted in the front window, but clients often take it down for their own use. The facility director was unable to locate the emergency telephone number displayed anywhere.
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Plan of Correction
A sign painting contractor has been contacted by the Projector Director and will be painting the hours of operation and emergency phone number on the door that is used by patients when they enter the building. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to provide documentation of at least 12 clock hours of annual training for the project director for the facility's 2009-2010 training year. The findings include:Eight personnel records were reviewed on September 20, 2010 through September 21, 2010. The facility's training year runs from July first through June thirtieth. Only six hours of annual training were provided for the project director for the facility's training year running from 7/1/09 through 6/30/10. During a discussion, the project director admitted he did not have twelve hours of annual training.
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Plan of Correction
The project director has already met this requirement for the current training year by recently attending the full duration of the AATOD conference. We are committed to meeting this requirement in the future with a full twelve hours of training annually regardless of work schedule. |