INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection to the initial on-site licensure inspection conducted on December 1, 2009 by staff from the Division of Drug and Alcohol Program Licensure. The follow-up inspection was conducted on June 16, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Bucks County Counseling 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 and a plan of correction is due on July 17, 2010.
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Plan of Correction
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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 the review of personnel records, the facility failed to document fire extinguisher training upon staff employment.
The findings include:
Two staff records were reviewed on June 16, 2010 to verify that staff had been instructed in the use of a fire extinguisher upon employment..
The facility failed to document the completion of fire extinguisher training upon staff employment in one of two personnel records reviewed, # 2.
Employee # 2 was hired January 2010.
The training was due upon employment, the training was not documented at the time of review on 6/16/10.
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Plan of Correction
The project director will be responsible for maintaining compliance and will conduct training on fire extinguisher equipment for employee #2 by 6/18/10. This training has already been completed and documented in the employee 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 the review of personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
The findings include:
Two personnel records were reviewed on June 16, 2010, both records required documentation to verify that all personnel on all shifts were trained to perform assigned tasks during emergencies.
The facility did not document that emergency training was provided upon employment in personnel record # 2.
Personnel # 2 was employed on January 2010, but verification of this training was not documented at the time of review on 6/16/10.
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Plan of Correction
The project directorwill be responsible for maintaining compliance and will conduct training on assigned tasks during emergencies for employee #2 by 6/18/10. This training has already been completed and documented in the employee file. |
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
Based on a review of client records, the facility failed to document a treatment plan update at least every 60 days in one of two records reviewed.
The findings include:
Two client records requiring treatment plan updates were reviewed on June 16, 2010.
The facility did not document an update in client record # 2.
Client # 2 was admitted to the program on 3/29/10.
The preliminary and comprehensive treatment plans were completed on 3/29/10. There were no treatment plan update in the client record at the time of review on 6/14/10.
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Plan of Correction
The project director will be responsible for maintaining compliance and will direct therapist #2 to create with client an update to the treatment plan by 6/18/10. In addition, a reveiw of the documentation requirements will be conducted with all therapists by 6/18/10. This update has already been completed and documented in the client file. The review of requirements has already been completed. |