INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the September 24, 2012 licensure renewal inspection and on-site initial licensure inspection. The follow-up inspection and initial licensure inspection were conducted on April 11, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection and initial licensure inspection, The Children's Service Center of Wyoming Valley 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:
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Plan of Correction
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704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
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Observations
Based on an interview with the facility director, the facility failed to develop an overall plan for addressing staff training needs.The findings include:The facility's policy titled: "(a) Policy addressing staff training needs," states:"The Facility Director, in cooperation with the Human Resources Department, will use the information collected in the surveys, along with the information collected throughout the year about training experiences, to create a plan for addressing both the Program's needs and individual staff needs through the staff development program planned for the coming year. This phase will be completed by January 1, the beginning of the training year."On April 11, 2013, the Licensing Specialist asked to see a copy of the facility's overall plan for addressing staff training needs. The facility's overall plan for addressing staff training needs was due by January 1, 2013. However, a copy of the facility's overall plan for addressing staff training needs was not presented for review. The findings were confirmed during an interview with the facility director on April 11, 2013 at approximately 11:00 A.M.
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Plan of Correction
An approved Plan of Correction is not on file. |
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.
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Observations
Based on a review of personnel records, the facility failed to instruct staff in the use of the fire extinguisher upon the date the facility began providing services in two of two personnel records reviewed.The findings include:On April 11, 2013, two personnel records requiring documentation of fire extinguisher training were reviewed. The facility did not provide documentation that they instructed staff in the use of the fire extinguisher upon the date the facility began providing services in two of two personnel records reviewed, specifically, personnel records # 1 and 5.Employee # 1 is the project director. The facility began providing services on October 18, 2012. Employee # 1 has been employed in his position since the program began providing services. Employee # 1 was due to complete fire extinguisher training upon the date the facility began providing services. However, personnel record # 1 did not include documentation of fire extinguisher training as of April 11, 2013.Employee # 5 is a counselor. The facility began providing services on October 18, 2012. Employee # 5 has been employed in her position since the program began providing services. Employee # 5 was due to complete fire extinguisher training upon the date the facility began providing services. However, personnel record # 5 did not include documentation of fire extinguisher training as of April 11, 2013. The findings were confirmed during an interview with the facility director on April 11, 2013 at approximately 11:00 A.M.
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Plan of Correction
An approved Plan of Correction is not on file. |
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.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies upon the date the facility began providing services in two of two personnel records reviewed.The findings include:On April 11, 2013, two personnel records requiring documentation that all personnel on all shifts had been trained to perform assigned tasks during emergencies were reviewed. The facility did not ensure that all personnel on all shifts completed emergency training upon the date the facility began providing services in two of two personnel records reviewed, specifically, personnel records # 1 and 5. Employee # 1 is the project director. The facility began providing services on October 18, 2012. Employee # 1 has been employed in his position since the program began providing services. Employee # 1 was due to complete emergency training upon the date the facility began providing services. However, personnel record # 1 did not include documentation of emergency training as of April 11, 2013.Employee # 5 is a counselor. The facility began providing services on October 18, 2012. Employee # 5 has been employed in her position since the program began providing services. Employee # 5 was due to complete emergency training upon the date the facility began providing services. However, personnel record # 5 did not include documentation of emergency training as of April 11, 2013.The findings were confirmed during an interview with the facility director on April 11, 2013 at approximately 11:00 A.M.
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Plan of Correction
An approved Plan of Correction is not on file. |
709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
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Observations
Based on a review of client records, the facility failed to document client orientation to the project that includes project policies in two of two records reviewed. On April 11, 2013, two client records requiring documentation of client orientation to the project that includes project policies were reviewed. The facility did not document project policies in two of two records reviewed, specifically, client records # 1 and 2.Client # 1 was admitted February 20, 2013. Client orientation to the project that includes project policies was due upon the client's admission by February 20, 2013. However, client record # 1 did not include documentation of client orientation to the project that included project policies as of April 11, 2013.Client # 2 was admitted March 25, 2013. Client orientation to the project that includes project policies was due upon the client's admission by March 25, 2013. However, client record # 2 did not include documentation of client orientation to the project that included project policies as of April 11, 2013. The findings were confirmed during an interview with the facility director on April 11, 2013 at approximately 11:00 A.M.
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Plan of Correction
An approved Plan of Correction is not on file. |
709.91(b)(2)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(ii) Hours of operation.
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Observations
Based on a review of client records, the facility failed to document client orientation to the project that includes hours of operation in two of two records reviewed. On April 11, 2013, two client records requiring documentation of client orientation to the project that includes hours of operation were reviewed. The facility did not document project policies in two of two records reviewed, specifically, client records # 1 and 2.Client # 1 was admitted February 20, 2013. Client orientation to the project that includes hours of operation was due upon the client's admission by February 20, 2013. However, client record # 1 did not include documentation of client orientation to the project that included hours of operation as of April 11, 2013.Client # 2 was admitted March 25, 2013. Client orientation to the project that includes hours of operation was due upon the client's admission by March 25, 2013. However, client record # 2 did not include documentation of client orientation to the project that included hours of operation as of April 11, 2013. The findings were confirmed during an interview with the facility director on April 11, 2013 at approximately 11:00 A.M.
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Plan of Correction
An approved Plan of Correction is not on file. |
709.91(b)(2)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iii) Fee schedule.
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Observations
Based on a review of client records, the facility failed to document client orientation to the project that includes a fee schedule in two of two records reviewed. On April 11, 2013, two client records requiring documentation of client orientation to the project that includes a fee schedule were reviewed. The facility did not document project policies in two of two records reviewed, specifically, client records # 1 and 2.Client # 1 was admitted February 20, 2013. Client orientation to the project that includes a fee schedule was due upon the client's admission by February 20, 2013. However, client record # 1 did not include documentation of client orientation to the project that included a fee schedule as of April 11, 2013.Client # 2 was admitted March 25, 2013. Client orientation to the project that includes a fee schedule was due upon the client's admission by March 25, 2013. However, client record # 2 did not include documentation of client orientation to the project that included a fee schedule as of April 11, 2013. The findings were confirmed during an interview with the facility director on April 11, 2013 at approximately 11:00 A.M.
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Plan of Correction
An approved Plan of Correction is not on file. |
709.91(b)(2)(iv) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iv) Services provided.
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Observations
Based on a review of client records, the facility failed to document client orientation to the project that includes services provided in two of two records reviewed. On April 11, 2013, two client records requiring documentation of client orientation to the project that includes services provided were reviewed. The facility did not document project policies in two of two records reviewed, specifically, client records # 1 and 2.Client # 1 was admitted February 20, 2013. Client orientation to the project that includes services provided was due upon the client's admission by February 20, 2013. However, client record # 1 did not include documentation of client orientation to the project that included services provided as of April 11, 2013.Client # 2 was admitted March 25, 2013. Client orientation to the project that includes services provided was due upon the client's admission by March 25, 2013. However, client record # 2 did not include documentation of client orientation to the project that included services provided as of April 11, 2013. The findings were confirmed during an interview with the facility director on April 11, 2013 at approximately 11:00 A.M.
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Plan of Correction
An approved Plan of Correction is not on file. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of a client record, the facility failed to document a medical history in one of one record reviewed. The findings include:The facility's policy titled: "(a) 3 Procedures for Management of Treatment/Rehabilitation Services for Clients," states:"Assessment, evaluations, psychosocial/history formulation: At the first appointment with the counselor an alcohol and drug assessment tool will be given to the client. The counselor will also begin to compile a history/psychosocial record that covers most life domains and helps to give the counselor a starting point for treatment planning. Treatment planning: Treatment planning is the primary responsibility of counselor. It should be completed by the end of the second session but may extend to the third session if the counselor is continuing to gather information." On April 11, 2013, one client record requiring documentation of a medical history was reviewed. The facility did not document a medical history in one of one record reviewed, specifically, client record # 1.Client # 1 was admitted February 20, 2013. The medical history was due by the third session on March 6, 2013. However, client record # 1 did not include documentation of a medical history as of April 11, 2013. The findings were confirmed during an interview with the facility director on April 11, 2013 at approximately 11:00 A.M.
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Plan of Correction
An approved Plan of Correction is not on file. |
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.
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Observations
Based on a review of a client record, the facility failed to document a drug or alcohol history in one of one record reviewed. The findings include:The facility's policy titled: "(a) 3 Procedures for Management of Treatment/Rehabilitation Services for Clients," states:"Assessment, evaluations, psychosocial/history formulation: At the first appointment with the counselor an alcohol and drug assessment tool will be given to the client. The counselor will also begin to compile a history/psychosocial record that covers most life domains and helps to give the counselor a starting point for treatment planning. Treatment planning: Treatment planning is the primary responsibility of counselor. It should be completed by the end of the second session but may extend to the third session if the counselor is continuing to gather information." On April 11, 2013, one client record requiring documentation of a drug or alcohol history was reviewed. The facility did not document a drug or alcohol history in one of one record reviewed, specifically, client records # 1.Client # 1 was admitted February 20, 2013. The drug or alcohol history was due by the third session on March 6, 2013. However, client record # 1 did not include documentation of a drug or alcohol history as of April 11, 2013. The findings were confirmed during an interview with the facility director on April 11, 2013 at approximately 11:00 A.M.
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Plan of Correction
An approved Plan of Correction is not on file. |
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.
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Observations
Based on a review of a client record, the facility failed to document a personal history that included a client's family history, employment/vocation history, educational history, military history, and sexual history in one of one record reviewed. The findings include:The facility's policy titled: "(a) 3 Procedures for Management of Treatment/Rehabilitation Services for Clients," states:"Assessment, evaluations, psychosocial/history formulation: At the first appointment with the counselor an alcohol and drug assessment tool will be given to the client. The counselor will also begin to compile a history/psychosocial record that covers most life domains and helps to give the counselor a starting point for treatment planning. Treatment planning: Treatment planning is the primary responsibility of counselor. It should be completed by the end of the second session but may extend to the third session if the counselor is continuing to gather information." On April 11, 2013, one client record requiring documentation of a personal history that included a client's family history, employment/vocation history, educational history, military history, and sexual history was reviewed. The facility did not document a client's family history, employment/vocation history, educational history, military history, and sexual history in one of one record reviewed, specifically, client records # 1. Client # 1 was admitted February 20, 2013. The personal history was completed on February 20, 2013 but did not include the client's family history, employment/vocation history, educational history, military history, and sexual history as of April 11, 2013. The findings were confirmed during an interview with the facility director on April 11, 2013 at approximately 11:00 A.M.
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Plan of Correction
An approved Plan of Correction is not on file. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of a client record, the facility failed to document a psychosocial evaluation in one of one record reviewed. The findings include:The facility's policy titled: "(a) 3 Procedures for Management of Treatment/Rehabilitation Services for Clients," states:"Assessment, evaluations, psychosocial/history formulation: At the first appointment with the counselor an alcohol and drug assessment tool will be given to the client. The counselor will also begin to compile a history/psychosocial record that covers most life domains and helps to give the counselor a starting point for treatment planning. Treatment planning: Treatment planning is the primary responsibility of counselor. It should be completed by the end of the second session but may extend to the third session if the counselor is continuing to gather information." On April 11, 2013, one client record requiring documentation of a psychosocial evaluation was reviewed. The facility did not document a psychosocial evaluation in one of one record reviewed, specifically, client records # 1.Client # 1 was admitted February 20, 2013. The psychosocial evaluation was due by the third session on March 6, 2013. However, client record # 1 did not include documentation of a psychosocial evaluation as of April 11, 2013.The findings were confirmed during an interview with the facility director on April 11, 2013 at approximately 11:00 A.M.
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Plan of Correction
An approved Plan of Correction is not on file. |
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:
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Observations
Based on a review of client records, the facility did not document individual treatment and rehabilitation plans that were individualized and included short-term and/or long-term goals, type and frequency, and proposed type of support services in two of two client records reviewed.The findings include:On April 11, 2013, two client records requiring documentation of an individual treatment and rehabilitation plan were reviewed. The facility documented individual treatment and rehabilitation plans. However, the facility did not document individual treatment and rehabilitation plans that were individualized and included short-term and/or long-term goals, type and frequency, and proposed type of support services in two of two client records reviewed, specifically, client records # 1 and 2.Client # 1 was admitted February 20, 2013. The individual treatment and rehabilitation plan was completed February 27, 2013. However, the individual treatment and rehabilitation plan was not individualized, only included one long-term goal, and did not include short-term goals, type and frequency of treatment, and proposed type of support services as of April 11, 2013.Client # 2 was admitted March 25, 2013. The individual treatment and rehabilitation plan was completed March 25, 2013. However, the individual treatment and rehabilitation plan was not individualized, did not include short-term and long-term goals, type and frequency of treatment, and proposed type of support services as of April 11, 2013.The findings were confirmed during an interview with the facility director on April 11, 2013 at approximately 11:00 A.M.
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Plan of Correction
An approved Plan of Correction is not on file. |