INITIAL COMMENTS
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This is an on site licensure renewal inspection conducted on 3/20/2006 to 4/13/2006 by staff from the Division of Drug and Alcohol Program Licensure . The following deficiencies were identified during this inspection and a plan of correction is due on May 19, 2006.
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Plan of Correction
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
The required 25 hours of training for counselors could not be verified for all staff reviewed in the sample. Specific records with incomplete documentation were records numbers 57, 59, 60 and 61.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
705.5 (a) (1) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(a) In each residential facility bedroom, each resident shall have the following:
(1) A bed with solid foundation and fire retardant mattress in good repair.
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Observations
Mattresses in the adolescent unit had cracked mattress covers. One mattress had no cover at all. Mattresses must be kept in good repair.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
705.5 (a) (2) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(a) In each residential facility bedroom, each resident shall have the following:
(2) A pillow and bedding appropriate for the temperature in the facility.
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Observations
Pillows needed to be replaced in several of the units inspected. Pillows had cracked or missing covers in areas reviewed.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
The adolescent unit had folding doors covering the lavatory areas in the individual client rooms. The doors were broken and the fabric on the doors was ripped in many of these rooms.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Exhaust fans were not operational in one section of the building at the time of the inspection.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Alternate exit routes must be prepared and documentation must reflect which exits are used during fire drills. Documentation was not clear in records presented.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
709.81(b)(3)(ii) LICENSURE Intake and admission
709.81. 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
Drug and alcohol histories in records reviewed did not provide a complete picture of the client's drug use patterns. Incomplete histories were noted in the following records: #19, 20, 21 and 22.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
709.81(b)(3)(iii) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Personal histories must be constructed to collect as much information about the client as possible. Histories were incomplete. They generally lacked detail and frequently did not address all areas required by this regulation. Incomplete histories were noted in records # 19, 20, 21 and 22.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
709.81(b)(6) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
The psychosocial evaluations were incomplete and were frequently not evaluative, but reiterations of historical data. The agency needs to ensure that a complete picture of the client is developed and that the client's needs are clearly identified and that an assessment is made of the impact those problems and needs will have on the recovery effort. The evaluation pieces were written so sparsely that they failed to support the treatment plan goals and objectives. The psychosocial evaluation should include enough information to clearly support the treatment plan goals developed for each client. Records #19, 20, 21, 22 were incomplete.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
709.83(a)(4) LICENSURE Client records
709.83. 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:
(4) Case consultation notes.
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Observations
Case consultation notes did not address all areas required . Three files which were reviewed required case consults , one record , # 21, missed the date of the consultation and the staff involved.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
709.83(a)(5) LICENSURE Client records
709.83. 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) Medication records.
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Observations
Medication records in files reviewed were incomplete. All medications being taken by a client whether prescribed by the project's physician or the client's private physician should be recorded in the chart indicating the name of the drug, dosage, and frequency of use. Problems were noted in record numbers: 19, 20, 21 and 22.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
709.83(a)(10) LICENSURE Client records
709.83. 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.
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Observations
Discharge summaries did not consistently address all areas required. Incomplete or late discharge summaries were noted in the following records: #19 and #20.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
709.83(a)(11) LICENSURE Client records
709.83. 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.
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Observations
Follow up was not documented for all types of discharges. Where clients are not referred after discharge, some attempt should be made to follow-up the client's progress and status in accordance with the agency's written policy.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Releases in a number of files reviewed were not completed completely and hence did not constitute an informed consent from the client. Consents must meet all requirements specified in applicable law and regulation. This issue was noted in the following records: # 6, 7, 8, 9, 12, 13, 15, 16, 17, 21, 22, 23, 24 and 25.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
709.28(c)(2) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Information released to entities addressed under the requirements of 4 Pa. Code subsection 255.5(b)exceeded the defined parameters. Information to be released was not completed on several forms found in the randomly selected charts that were reviewed. The following records were not in compliance with this regulation, #3, 6, 7, 8, 9, 13, 20 and 21.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
709.31(b) LICENSURE Uniform Data Collection System
709.31. Uniform Data Collection System.
(b) A data collection and record-keeping system shall be developed that allows for the efficient retrieval of data needed to measure the project's performance in relationship to its stated goals and objectives.
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Observations
The record retrieval process during the licensing inspection was inefficient. Agency policy regarding storage of closed records at the main site was not consistently followed.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
One applicable record was reviewed (19) and it did not contain notification to the client of involuntary termination.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
709.63(a)(8) LICENSURE Follow-up Information
709.63. 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:
(8) Follow-up information.
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Observations
Follow up was not documented for all types of discharges. Where clients are not referred after discharge, some attempt should be made to follow-up on the client's progress and status in accordance with the agency's written policy.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
709.51(b)(3)(ii) LICENSURE Drug & Alcohol History
709.51. 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
Drug and alcohol histories did not present a complete picture of the client's patterns of use, perceptions about their use or drugs of choice in the records reviewed. A history must document the substances most frequently abused, the length and patterns of use and prior treatment episodes and include the client's perception of their effect on his/her social, physical and mental state. It is recommended that any substance abuse history within the family, or that of significant others be noted.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
709.51(b)(3)(iii) LICENSURE Personal History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Personal histories did not address all areas in sufficient detail to meet the requirements of this regulation. Incomplete historical information was noted in each record reviewed. Histories should be constructed to gather as much detail as possible to provide a basis for meaningful evaluation and treatment plan formulation.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Psychosocial evaluations did not address required areas. Evaluations did not contain detailed clinical impressions. The evaluation should provide a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation. Incomplete evaluations were noted in all files reviewed.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
709.51(b)(7) LICENSURE Preliminary Tx. Plan.
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Preliminary treatment plans were missing or late in the following records, #2, 4, 7, 10, 11 and 8. A Preliminary Treatment Plan should be based upon information derived from the initial interview, psychosocial and other evaluations. This plan should also identify critical client problems and strategies for their resolution.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Treatment plan updates were late or missing in the following records reviewed, #12, 13, 23 and 24. The treatment plan update should include an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
709.53(a)(9) LICENSURE Aftercare plans
709.53. 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.
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Observations
Aftercare plans were missing in all closed records reviewed, #6, 7, 8, 9 and 10.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
709.53(a)(10) LICENSURE Discharge Summary
709.53. 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.
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Observations
Discharge summaries did not address required areas in the following records reviewed, #6, 7, 8, 9 and 10. Within one week after discharge, there should be entered into the client's case record a discharge summary describing the reasons for treatment, services offered, response to treatment and client's status or condition upon discharge.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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.
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Observations
Follow up was not documented for all types of discharges. Where clients are not referred after discharge, some attempt should be made to follow-up on the client's progress and status in accordance with the agency's written policy.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
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.
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Observations
Follow up was not documented for all types of discharges. Where clients are not referred after discharge, some attempt should be made to follow-up the client's progress and status in accordance with the agency's written policy.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |