INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on December 17, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Community Counseling Center of Mercer County 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 January 19, 2009.
|
Plan of Correction
|
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.
|
Observations
Based on a review of eight training/personnel records on December 17, 2008, the facility failed to provide the required fire extinguisher training at the time of employment. The fire extinguisher training was not documented in two of eight personnel records where required.
Finding:
Eight employee training records were reviewed during the onsite licensing inspection of December 17, 2008. All were required to have documentation of fire extinguisher training within seven days of hire date. Records # 4 and 6 did not have documentation that the employees received the required fire extinguisher training in the required time frame.
|
Plan of Correction
The procedure in place for hiring new employees has been amended to include fire extinquisher training as part of the initial hiring paperwork. This will avoid a time lapse of more than seven days occuring before the next monthly orientation. This change will be implemented by HR and monitored by the compliance officer.It is effective 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.
|
Observations
Based on a review of eight training/personnel records on 10-9-08, the facility failed to provide the required emergency training at the time of employment. The emergency training was not documented in two of eight personnel records where required.
Finding:
The facility did not document emergency training in personnel records #4 and 6 within seven days of hire date.
|
Plan of Correction
The hiring procedure has been amended to include a review of fire drill routes and process. This will prevent a time lapse between date of hire and the agency monthly orientation. This will be implemented by HR and monitored by the compliance officer. It is effective immediately. |
709.28(c) 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:
|
Observations
Based on a review of client records, the facility failed to document release of information forms that provided an informed consent.
The findings include:
Four records were reviewed on December 17, 2008. All four records were required to include release of information forms that provided an informed consent. Release of information forms for the Behavioral Health Commission, Probation, Mercer County Court Administrator, and CYS included an information section identified as "Intake Information"; client record documentation did not specify what information was released. This was noted in records #1, 2 and 3. In addition,client record #2 contained a copy of a letter sent to an attorney, but there was no release of information form signed to allow that disclosure.
|
Plan of Correction
The issue with the confidentiality of records was two fold. The first was a form-building issue within the software which had included the additional "intake Information" selection. This was inadvertantly added to all consent forms. It has been removed from all Drug and Alcohol consents, as of the licensing visit.
The second problem with the consents was also related to the format and labling of the forms within the software. While the consent was included, it was not the correct form and had been rewritten in a way that was not evident of covering the cited letter. This has also been rectified in the software. The forms have been altered slightly and the labling clarified to allow correct use of the forms. This action has already been completed and staff has been updated on the changes.
The compliance officer will be responsible for monitoring the use of the consent forms and their content. |