INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection report for the visit conducted on July 10, 2006 through July 11, 2006 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during the inspection and a plan of correction is due on August 8, 2006.
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Plan of Correction
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709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
The facility has documented the goals and objectives, however they have not been approved by the board.
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Plan of Correction
0147 709.23(b)(1) Project Director-Goals and Objectives
8/31/06
POC: PHS Board met on August 7, 2006 and approved the 06-07 agency goals and objectives. For 06-07 this standard is now in full compliance. For 07-08 the project director will assist the board in formulating goals and objectives at the April 2007 Board meeting with final approval at their June 2007 meeting.
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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
The specific information to be released to the insurer was not specific as it stated "information as needed", in client record #6.
The specific information to be released to CYS exceeded that allowed by 4 Pa. Code 255.5 in client record #1.
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Plan of Correction
0279 709.28(c)(2) Confidentiality-Specific Information
8/31/06
POC: At the July 17, 2006 treatment meeting the clinical supervisor reviewed with the counselors the criteria for release of information. Clinical supervisor will review more closely the correspondence to be sent as well as completion of the consent forms during client file review. Standard will be in full compliance as of August 31.
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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 did not include a composite picture of the client in records #1, 3, and 5. Coping mechanisms were not identified in records #1, 3, 4, and 7. The clinicians's assessment of the client was not indicated in client records #1 and 3.
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Plan of Correction
1871 709.91(b)(6) Psychosocial Evaluation
8/31/06
POC: At the July 17, 2006 treatment meeting the clinical supervisor reviewed with the counselors to document a composite picture of the client in the psychosocial history and evaluation. Clinical supervisor will review more closely these two forms during each client file review to ensure complete documentation. Standard will be in full compliance by August 31.
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709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Discharge summaries did not include reasons for this treatment experience or the client's response to treatment plan goals in two of seven client records reviewed, specifically # 3 and 7.
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Plan of Correction
1909 709.93(a)(10) Discharge Summary
8/31/06
POC: Discharge summary form has been revised (July 24 revision) to include reason for treatment experience. Clinical supervisor reviewed with the counselors at the July 17 treatment meeting to document in the discharge summary the reason for the treatment experience and client's response to treatment goals. Clinical supervisor will review more closely the client file at the time of discharge to ensure that these two area are completed. This standard will be in full compliance by August 31.
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704.5(a) LICENSURE Project/Facility Director
704.5. Qualifications for the positions of project director and facility director.
(a) A drug and alcohol treatment project shall have a project director responsible for the overall management of the project and staff and each drug and alcohol treatment facility shall have a facility director responsible for the overall management of the facility and staff unless the project has but one facility.
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Observations
Applying the criteria outlined in the Licensing Alert 05-05, the identified project director does not perform the functions of this position. The Executive Director is performing these functions, but does not meet the qualifications for this position.
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Plan of Correction
0021 704.5(a) Project/facility Director
8/21/06
POC: Executive Director will submit by August 31 a request for exception for 704.5 (a) for the Executive Director to be project director. Upon receiving approval from licensure for this request, this standard would be in full compliance. If notified that the exception is not granted, the contingency plan is for Staff Person #1 to perform duties as the project director.
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