INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 11,2006 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 June 15, 2006.
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Plan of Correction
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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
No documentation was on file to document that the counselor assistant employed during the review period was supervised in accordance with the requirements of this regulation.
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Plan of Correction
An approved Plan of Correction is on file with the Department of Health. |
705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
One of the marked exits from the second floor is equipped with a double key lock. The door was locked at the time of the of the inspection. This constitutes an obstruction to the exit. All designated fire exits are to remain unobstructed at all times.
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Plan of Correction
An approved Plan of Correction is on file with the Department of Health. |
709.81(b)(3)(i) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Client symptoms and illnesses were missed in the one record available for review. A history documenting the client's personal medical history, family medical history, and history of illness and symptoms should be collected for each client.
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Plan of Correction
An approved Plan of Correction is on file with the Department of Health. |
709.81(b)(4) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Consent to treatment was not documented for the one file available for review. Each file must contain a valid consent to treatment.
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Plan of Correction
An approved Plan of Correction is on file with the Department of Health. |
709.82(e)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(1) Medical/dental.
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Observations
No documentation of the availability of dental support services was documented. Documentation must be presented to indicate that all required support services are available to clients.
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Plan of Correction
An approved 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
A re-disclosure statement included in the consent to release form implies that once the information is released to the other party, confidentiality laws may no longer apply. Although the facility giving the information is not responsible if the recipient re-releases the information once they have made them aware that it is illegal, the information is always protected. This form is giving the client to whom it pertains inaccurate information. This form was found in all client charts reviewed.
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Plan of Correction
An approved 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
Consents in records reviewed had a criminal justice consent to release information which stated that "all recommendations" would be released. This terminology was found in records # 1,2,4,5 and 7. Specific information to be disclosed must be stated in order to meet the requirements for an informed consent. Record # 1 exceeded the parameters of 4 Pa. Code subsection 255.5(b).
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Plan of Correction
An approved Plan of Correction is on file with the Department of Health. |
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
Medical histories did not address all areas required in record # 2. No medical history was located in record # 5. A history documenting the client's personal medical history, family medical history, and history of illness and symptoms must be collected for each client.
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Plan of Correction
An approved Plan of Correction is on file with the Department of Health. |
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
Drug and alcohol histories were incomplete in records # 2 and 7. Record # 5 did not have a drug and alcohol history. A history documenting the substances most frequently abused, the length and patterns of use, and prior treatment episodes must be collected. The history must also Include the client's perception of the effect of substance use/abuse 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
An approved Plan of Correction is on file with the Department of Health. |
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
Personal histories generally lacked sufficient detail. Histories were found to be incomplete in records # 1,2,and 7. No history was located in file #5. Historical and pertinent personal data including: family, legal, employment/vocational, educational, military, recreational, sexual, and others where appropriate should be included in each history.
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Plan of Correction
An approved Plan of Correction is on file with the Department of Health. |
709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
None of the records reviewed at this facility had consents to treatment documented. A consent to treatment form should be signed by both the client and the staff person at intake. This consent could be integrated with other forms/procedures, e.g., liability determination, preliminary treatment plan, intake and orientation verification.
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Plan of Correction
An approved Plan of Correction is on file with the Department of Health. |
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
Psychosocial evaluations in records # 2, 4, 5 and 6 did not address all required areas in sufficient depth . Areas missed included the composite picture, coping mechanisms, support systems and detailed clinical impressions.
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Plan of Correction
An approved Plan of Correction is on file with the Department of Health. |
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
Treatment plans reviewed in records # 1, 2 4 ,5 and 7 had goals and objectives which were general in nature and not individualized to meet the client's specific needs. Plans should be developed to meet the assessed needs of each client.
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Plan of Correction
An approved Plan of Correction is on file with the Department of Health. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Treatment plan updates were missed in file # 5 and file #2. Updates must be completed every sixty days for outpatient clients.. 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
An approved Plan of Correction is on file with the Department of Health. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Aftercare plans were missed in two of three applicable records (# 1 and 7 ).
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Plan of Correction
An approved Plan of Correction is on file with the Department of Health. |