INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 9, 2007 - November 13, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Alliance Medical Services 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 7, 2007.
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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 review of the "Staffing Requirements Facility Summary Report" form employee # 3 did not complete the 6 hours of Department of Health approved HIV/AIDS training or the four hours of TB/STD or other communicable diseases training within the required time frames.
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Plan of Correction
Employees #3 did not complete the mandatory training in either HIV/AIDS or TB/STD.
The identified employees will attend the required trainings as soon as the specific trainings are offered locally. At a minimum, the identified staff will be trained within the next ninty days.
The Clinical Supervisor will be responsible for compliance in this matter. |
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
Based on review of the client records it was determined that the facility failed to include progression of the clients, substance abuse relative to the lengths and patterns of use. The client's progression of substance use/abuse was missing in 8 out of 8 client records reviewed.
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Plan of Correction
Staff will be trained to include the progression of substance abuse relative to the lengths and patterns of use. The biopsychsocial history will also be amended to more clearly identify and explain these issues.
The Facility Director will be responsible for amending the form and for providing training in this area. The Facility Director and the Clinical Supervisor will be responsible for ongoing compliance. |
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
Based on reviews of client records it was determined that the facility failed to ensure that the personal histories were complete. Personal histories in eight of eight records reviewed were incomplete relative to family histories, recreational histories, employment histories, educational histories, legal histories, and sexual histories.
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Plan of Correction
Staff will be trained to document complete personal histories relative to family, employment, educational, legal and sexual histories. The biopsychsocial evaluation will also be amended to more clearly identify and explain these issues.
The Facility Director will be responsible for amending the form and for providing training in this area. The Facility Director and the Clinical Supervisor will be responsible for ongoing compliance. |