INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 20, 2006 through September 21, 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 October 23, 2006.
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Plan of Correction
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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
There is insufficient first aid and CPR coverage on second and third shifts for the month of September.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 information to be released to funding sources exceeded that allowed by 4 Pa. Code 255.5 in two of four client records reviewed, # 2 and 3.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
The psychosocial evaluations did not include a composite picture, coping mechanisms or an assessment of the impact of the client's assets/strengths in two of four client records reviewed, # 3 and 4. Additionally, the psychosocial evaluations did not assess the impact of the client's assets/strengths and negative factors that may inhibit treatment in two of four client records reviewed, # 1 and 2.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
The type and frequency of treatment and rehabilitation services was missing on treatment plans in four of four client records reviewed, # 1, 2, 3 and 4.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
The treatment plan updates did not include a review of progress with regards to the goals and action steps from the prior treatment plans in three of four client records reviewed, # 1, 2 and 3.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |