INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 10, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Truenorth Wellness Services was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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704.2(b) LICENSURE Staffing Plan
704.2. Compliance plan.
(b) The plan documenting the qualifications and training of staff shall be presented to Department licensing representatives at the time of the project's site visit.
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Observations
The facility failed to meet the pre-submission guidelines for the annual licensing inspection. The time allotted for the onsite portion of the inspection did not allow for a thorough review of that material on site.
This matter was reviewed with facility staff during the licensing process.
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Plan of Correction
The Drug and Alcohol Director will complete and submit to DDAP, the DDAP staff training form promptly following receipt. The completed staffing form will be reviewed with the Facility Manager prior to submission to DDAP. If there are questions regarding the proper response, DDAP will be contacted for guidance prior to submission of the form. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Five personnel records were reviewed on August 10, 2016. Four out of the five personnel records were required to contain an annual evaluation. The facility failed to document an annual evaluation in employee record # 2.
Employee #2 was hired on June 18, 2001, and there was no documentation of an annual evaluation since October 2014.
These findings were reviewed with facility staff during the licensing process
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Plan of Correction
The Project Director will complete an annual performance evaluation for employee #2 prior to October 1, 2016.
To ensure this does not recur, the TrueNorth Wellness Director of Drug and Alcohol Program will verity with HR by the second week in October that the performance evaluation is in the HR file. If it is not, the Drug and Alcohol Director will directly e-mail the CEO and inform them of the need to complete the performance evaluation. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Two patient records were reviewed on August 15, 2016 for documentation of initial drug- screening urinalysis at the time of admission or re-admission. The facility failed to document when the urine test was collected in patient record # 2.
Client #2 was admitted on August 4, 2016 and dosed on August 4, 2016. A urine test was completed but the facility failed to obtain the result of the urine screen prior to administering intial dose.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The initial urine screening process is overseen by the physician. The physician will review results of the urine screen prior to prescribing medication for all new clients.
The physician will enter the results of the urine screen into the medical record.
This process will be initiated September 1, 2016. |