INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 27, 2006 and June 29, 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 July 21, 2006.
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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
Employee numbers 11, 12, and 13 have not had fire extinguisher training. Employee number 10 had the training 16 days from the date of employment. Instruction may be included in the employee orientation, but must occur no later than seven days from the date of employment.
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Plan of Correction
The New Employee Orientation Checklist will be modified to include fire extinguisher training ( to occur within 7 days of employment). The Associate Director will review all new employee personnel files within 1 week of hire to assure all orientation activities, inclusive of fire extinguisher training,have been completed. This corrective action will go into effect immediately. |
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
Employee numbers 11, 12, and 13 have not had emergency procedures training. Employee number 10 had the training 16 days from the date of employment. This training, as with the fire extinguisher training, may be included in the employee orientation, but must occur no later than seven days from the date of employment.
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Plan of Correction
The New Employee Orientation Checklist will be modified to include completion of training on emergency procedures ( to occur within 7 days of employment ). The Associate Director will review all new employee personnel files, within 7 days of hire, to assure all orientation activities, include orientation to emergency procedures, have been completed. This corrective action will go into effect immediately. |
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
Client record numbers 1, 2, 5, 7, 8, 10, 13, 14, and 15 had various confidentiality issues that consisted of:
1. PCPC summary reports that included the drug of choice and the last use date.
2. Consents to CCBH, TASC, and Children and Youth that included discharge summaries, psychiatric evaluations, and medication records. This information exceeds the limits imposed at 4 Pa. Code Subsection 255.5(b).
3. Bi-Weekly follow up reports to the RIPP/IPP program (government officials) that included the results of a urine screen and the drug identified in a positive urine screen. This information exceeds the limits imposed at 4 Pa. Code Subsection 255.5(b).
4. Request for Authorization - Treatment Access Services Center forms included medical, drug and alcohol, and personal history information that exceeds the limits imposed at 4 Pa. Code 255.5(b).
5. A discharge summary included the results of a drug screen. This information exceeds the limits imposed at 4 Pa. Code Subsection 255.5(b).
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Plan of Correction
Clinical Supervisor will hold a clinical in service-- by no later than 8/1/06--reviewing all policies and procedures related to confidentiality and 4 Pa. Code Subsection 255.5. This shall include the limiting of information on PCPCs, releases of information, progress reports,authorization requests and discharge summaries to that allowed by these guidelines. The Continuous Quality Improvement Committee, under the direct supervision of the Associate Director, shall be responsible for random review of records and ongoing compliance with regard to this standard. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Client record numbers 3 and 4 did not have preliminary treatment plans.
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Plan of Correction
Clinical Supervisor will hold a clinical in service, by 8/1/06, reviewing the policies and procedures related to the completion of a preliminary treatment plan. The preliminary treatment plan is to be completed at the client's first session. The Continuous Quality Improvement Committee, under the direct supervision of the Associate Director, will be responsible for random record reviews and ongoing monitoring of compliance with regard to this standard. |
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
Client record numbers 3 and 6 had updates that appeared to be dated within the time frames required by agency policy, rather than the date the document was actually produced. Therefore, compliance with the agency policy cannot be determined.
Client record number 4 was missing two updates.
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Plan of Correction
Clinical Supervisor will have a clinical in service, by no later than 8/1/06, to review the time frames for completion of treatment plan updates and the policy and procedure related to signatures and dating. If a due date falls on a weekend, and the update was completed that Friday or Monday, the actual date completed should be noted along with signature-- not the weekend date. The Clinical Supervisor will be responsible for reviewing treatment updates on a regular, random basis and assuring that policies regarding time frames, signatures, and dating are being followed. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Client record number 6 had a case consult that appeared to be dated within the time frames required by agency policy rather than the date the document was actually produced. Therefore, compliance with the agency policy cannot be determined.
Client record numbers 3, 4, and 10 did not have case consults.
Client record numbers 5 and 12 had case consults that were not collected within the 90 day time frame.
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Plan of Correction
The Clinical Supervisor will have a clinical in service, by no later than 8/1/06, to review the policies and procedures with regard to the time frames for completion of case consultations and the signing and dating of same. The signature and date should reflect the actual case consult date-- not the due date-- should that fall on a weekend. The Clinical Supervisor will be responsible for random review of record keeping to assure accurate signatures and dating. The Continuous Quality Improvement Committee, under the direct supervision of the Associate Director, will be responsible for random review of records and compliance with policies and procedures regarding frequency of case consultations. |