INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on August 13 - 15, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Cen-Clear Child Services, Inc. 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.
|
Plan of Correction
|
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
|
Observations
Based on a review of personnel records, the facility failed to document HIV/AIDS training in one of three staff records.
The findings include:
Eight personnel records were reviewed on August 13, 2012. Three personnel records required documentation of HIV/AIDS training. The facility failed to document HIV/AIDS training in personnel record # 5
Employee # 5 is a counselor and was hired on April 18, 2011. HIV/AIDS training was due to be completed no later than April 18, 2012. There was no documentation of HIV/AIDS training in personnel record # 5.
The facility director was interviewed throughout the licensing inspection and confirmed the findings.
|
Plan of Correction
THe Facility Director has implemented a tracking system of all staff members to monitor required new hire and annual trainings. This particular staff person has been scheduled to attend HIV/AIDS training in November 2012. This is the earliest one offered around this facility. |
709.93(a)(2) 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:
(2) Medication records.
|
Observations
Based on a review of client records, the facility failed to document medication records that indicated the name of the drug, dosage and frequency of use in two of two client records.
The findings include:
Nine client records were reviewed on August 14 - 15, 2012. Two client records required documentation of medication records. The facility failed to document a medication record that indicated the dosage in client record # 2. The facility failed to document a medication record that indicated the name of the drug, dosage and frequency of use in client record # 4.
Client # 2 was admitted into treatment on March 12, 2012. Client # 2 was prescribed Suboxone daily. The medication record did not document the dosage of this medication for client # 2.
Client # 4 was admitted into treatment on April 19, 2012. The medication record did not document the name of the drug, dosage and frequency of use for client # 4. The medication record is documented on the intake history form. The medication record was left blank on the intake history and it was not possible to determine whether or not the client was prescribed any medications.
The facility director was interviewed throughout the licensing inspection and confirmed the findings.
|
Plan of Correction
The Facility Director has scheduled a staff training on August 29, 2012 specific to our intake process, completeness of documentation and specifically review the medication record section, and timelines. All staff will be retrained in this specific requirements. The departmental assistant will review intake documentation to determine completion and return to staff person if deficiencies exist. |
709.93(a)(11) 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:
(11) Follow-up information.
|
Observations
Based on a review of client records, the facility failed to document follow-up information within 7 days of discharge, as per facility policy, in three of three client records.
The findings include:
Nine client records were reviewed on August 14 - 15, 2012. Five client records were closed and required documentation of follow-up information. Per agency policy, a follow-up will be conducted within 7 days of discharge. The facility failed to document follow-up information within 7 days of discharge in client records # 6, 8 and 9.
Client # 6 was admitted into treatment on August 10, 2010 and discharged on December 5, 2011. A follow-up attempt was due to be completed no later than December 12, 2011. Follow-up information for client # 6 was not documented until December 19, 2011.
Client # 8 was admitted into treatment on September 6, 2011 and discharged on December 15, 2011. A follow-up attempt was due to be completed no later than December 22, 2011. There was no documentation of follow-up information in client record # 8.
Client # 9 was admitted into treatment on February 1, 2012 and discharged on February 27, 2012. A follow-up attempt was due to be completed no later than March 5, 2012. There was no documentation of follow-up information in client record # 9.
The facility director was interviewed throughout the licensing inspection and confirmed the findings.
|
Plan of Correction
The Facility Directorh has updated the follow-up policy on July 9, 2012 that reflects that follow-ups will be conducted by the departmental assistants on all consumers that have been discharged at 30 day and 6 month following discharge. The policy also states the if a referral is made to an outside agency then a follow-up will be completed departmental assistants within 7 days of discharge. In addition, the Facility Director has implemented a tracking system that tracks the completion of follow-ups with the departmental assistants. |