INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 18 - 20, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Tadiso 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 and a plan of correction is due on December 18, 2009. .
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Plan of Correction
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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.
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Observations
Based on a review of personnel records and an interview with the project/facility director, the facility failed to provide documentation of TB/STD training in two of six personnel records.
The findings include:
Eleven personnel records were reviewed on November 18, 2009. Six personnel records were required to have documentation of TB/STD training. The facility did not provide documentation of the required TB/STD training in personnel records # 10 and 11.
Employee # 10 is a counselor and was hired on January 22, 2008. TB/STD training was due to be completed no later than January 22, 2009. The facility failed to provide documentation of TB/STD training as of November 20, 2009.
Employee # 11 is a nurse and was hired on September 24, 2007. TB/STD training was due to be completed no later than September 24, 2009. The facility failed to provide documentation of TB/STD training as of November 20, 2009.
The project/facility director confirmed that employees # 10 and 11 had not completed TB/STD training.
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Plan of Correction
Tadiso Inc. did not have two personnel trainied in STD/TB as mandated. The
Project Director will ensure that the criteria is met via a review of all staff records. Those who have not met the requirement will receive the approved DOH training by 2/28/10 |
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
Based on a review of administrative policies and procedures, client records and an interview with the project/facility director, the facility failed to document an aftercare plan in two of two client records, as required.
The findings include:
Twenty-four client records were reviewed on November 18 - 20, 2009. An aftercare plan was required in two client records. The facility aftercare policy is to develop the aftercare plan throughout the treatment process and complete prior to discharge from the program. The facility did not document an aftercare plan in client record # 11. The facility did not document an aftercare plan that included time frames in client record # 20.
In client record # 11, the client was admitted on July 24, 2004 and was discharged on June 10, 2009. The client successfully completed the treatment program. There was no documentation of an aftercare plan in the client record. The project/facility director was able to produce a copy of the aftercare plan from the electronic record system. The aftercare plan was not dated or signed by the counselor or client. It was not possible to determine when the aftercare plan was completed or if it was developed with input from the client. The aftercare plan did not include time frames for the completion of future goals.
In client record # 20, the client was admitted on June 5, 2009 and discharged on November 4, 2009. The client successfully completed the treatment program. An aftercare plan was completed prior to discharge; but did not include time frames for the completion of future goals.
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Plan of Correction
Tadiso Inc did not have after care plans in client files of two discharged clients. The Director of Social Serivce will provide training and intruction to counsleors regarding aftercare palns and adherence to Tadiso Inc. policy regarding the revision of the aftercare plan throughout the treatment process. Training and policy change regarding an after care plan update annually and/or when will client status dictates revision of the plan will be completed by Feburary 28, 2010. |