INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 13, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Community Service Foundation Inc. 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:
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Plan of Correction
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of client records, the facility failed to document an individual training plan that includes potential resources for training which meet the requirements for the employee's position and which relate to the employee's skill level and interest.The findings include:On December 12, 2012, ten records requiring documentation of an individual training plan were reviewed. The facility did not document an individual training plan that included potential resources for employees in eight of ten records reviewed, specifically, personnel records # 1, 3, 4, 5, 7, 8, 9, and 10.Employee # 1 is the project director and was hired for his current position on April 24, 2006. An individual training plan was completed on January 31, 2012; however, the individual training plan did not include potential resources for employee # 1.Employee # 3 is one of the clinical supervisors and was hired for his current position on September 1, 2009. An individual training plan was completed on February 28, 2012; however, the individual training plan did not include potential resources for employee # 3.Employee # 4 is one of the clinical supervisors and was hired for her current position on July 12, 2004. An individual training plan was completed on February 15, 2012; however, the individual training plan did not include potential resources for employee # 4.Employee # 5 is a counselor and was hired for her current position on February 1, 2000. An individual training plan was completed on February 15, 2012; however, the individual training plan did not include potential resources for employee # 5.Employee # 7 is a counselor and was hired for her position on March 10, 2005. An individual training plan was completed on February 7, 2012; however, the individual training plan did not include potential resources for employee # 7.Employee # 8 is a counselor and was hired for her current position on February 17, 2012. An individual training plan was completed on February 17, 2012; however, the individual training plan did not include potential resources for employee # 8.Employee # 9 is a counselor and was hired for her current position on October 14, 2011. An individual training plan was completed on February 6, 2012; however, the individual training plan did not include potential resources for employee # 9.Employee # 10 is a counselor assistant and was hired for her current position on January 9, 2012. An individual training plan was completed on July 16, 2012; however, the individual training plan did not include potential resources for employee # 10.The findings were confirmed during an interview with one of the clinical supervisors on December 13, 2012 at approximately 3:00 P.M.
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Plan of Correction
The project director will be responsible for implementing a plan for staff to include resources to their annual individual training plan. Directions for the training plan have been already changed to include resources for 2013 evaluations. There are also added directions within the document that ask that resources be included. The project director will ensure that resources are included on an ongoing basis. Completed 1/4/13. |
709.82(e)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(1) Medical/dental.
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Observations
Based on a review of letters of agreement and an interview with the project director, the project failed to assists clients in obtaining dental supportive services when necessary. The findings include:On December 12, 2012, the Licensing Specialist asked to see documentation that the facility assists clients in obtaining dental supportive services when necessary. Documentation that the facility assists clients in obtaining dental supportive services when necessary was not presented for review. The findings were confirmed during an interview with the project director on December 12, 2012 at approximately 10:30 A.M.
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Plan of Correction
The project director will ensure that documentation of dental relationships exist through client files or through Business Associate Agreements. The project director will begin to collect this documentation by 2/28/13 and ensure that ongoing relationships are established. The project director will ensure these agreements are current. |
709.82(e)(3) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(3) Legal.
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Observations
Based on a review of letters of agreement and an interview with the project director, the project failed to assists clients in obtaining legal supportive services when necessary. The findings include:On December 12, 2012, the Licensing Specialist asked to see documentation that the facility assists clients in obtaining legal supportive services when necessary. Documentation that the facility assists clients in obtaining legal supportive services when necessary was not presented for review. The findings were confirmed during an interview with the project director on December 12, 2012 at approximately 10:30 A.M.
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Plan of Correction
The project director will ensure that documentation of legal relationships exist through client files or through Business Associate Agreements. The project director will begin to collect this documentation by 2/28/13 and ensure that ongoing relationships are established. The project director will ensure these agreements are current.
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709.82(e)(4) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(4) Economic.
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Observations
Based on a review of letters of agreement and an interview with the project director, the project failed to assists clients in obtaining economic supportive services when necessary. The findings include:On December 12, 2012, the Licensing Specialist asked to see documentation that the facility assists clients in obtaining economic supportive services when necessary. Documentation that the facility assists clients in obtaining economic supportive services when necessary was not presented for review. The findings were confirmed during an interview with the project director on December 12, 2012 at approximately 10:30 A.M.
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Plan of Correction
The project director will ensure that documentation of economic supportive services and relationships exist through client files or through Business Associate Agreements. The project director will begin to collect this documentation by 2/28/13 and ensure that ongoing relationships are established. The project director will ensure these agreements are current. |
709.24(a)(3) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of the facility's policy and procedures manual, the facility failed to adopt a written plan for the coordination of client treatment and rehabilitation services which include policies and procedures that include time frames for completing the preliminary treatment and rehabilitation plan and the individual treatment and rehabilitation plan.The findings include:The facility's policy and procedure for preliminary treatment and rehabilitation plan of partial hospitalization titled: "709.81 Intake and Admission," states:"A preliminary treatment plan should be based on the aftercare plan of the primary treatment facility, if the client has been in residential treatment, and information from the initial interview, histories and other available data. The plan also identify critical problems and strategies for their resolution."The facility's policy and procedure for individual treatment and rehabilitation plan of partial hospitalization titled: "709.82 Treatment and Rehabilitation Services," states:"(a)An individual treatment plan is developed with each client and shall include:(1)Short and long-term goals for treatment as formulated by both staff and client. We pay special attention to the treatment plans developed by a primary treatment facility, particularly the aftercare plan. Goals are realistic and stated in terms of measurable criteria."The facility's policy and procedure for preliminary treatment and rehabilitation plan of outpatient activities titled: "709.91 Intake and Admission," states:"A preliminary treatment plan should be based on the aftercare plan of the primary treatment facility, if the client has been in residential treatment, and information from the initial interview, histories and other available data. The plan also identify critical problems and strategies for their resolution."The facility's policy and procedure for individual treatment and rehabilitation plan of outpatient activities titled: "709.92 Treatment and Rehabilitation Services," states:"(a)An individual treatment plan is developed with each client and shall include:(1)Short and long-term goals for treatment as formulated by both staff and client. We pay special attention to the treatment plans developed by a primary treatment facility, particularly the aftercare plan. Goals are realistic and stated in terms of measurable criteria."On December 11, 2012 and December 12, 2012, the facility's policy and procedures manual was reviewed for a written plan for the coordination of client treatment and rehabilitation services. The facility's policies and procedures on the preliminary treatment and rehabilitation plan and the individual treatment and rehabilitation plan for partial hospitalization and outpatient activities did not include time frames for completing the preliminary treatment and rehabilitation plan and the individual treatment and rehabilitation plan.The findings were confirmed during an interview with the project director on December 12, 2012 at approximately 10:30 A.M.
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Plan of Correction
The project director will be responsible to specify time frames for the preliminary, individual and rehabilitation plans within the policy and procedure manual. These additions to the policies will be created and supported by the board of directors by 3/1/13. The project director will ensure the revised policy and procedure will be implemented and remain in place at the facility. |
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:
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Observations
Based on a review of client records, the facility failed to ensure that the client is notified of his/her right to revoke client consent to release information verbally or in writing.The findings include:On December 13, 2012, seven records requiring documentation of consent to release information were reviewed. The facility's consent to release form had verbiage that only gave the client the right to revoke in writing in seven of seven records reviewed, specifically, client records # 1, 2, 3, 4, 5, 6, and 7.Client record #1 contained an informed and voluntary consent dated 4/2/12 to a government agency and an informed and voluntary consent dated 4/2/12 to his mother. The forms used as the informed and voluntary consents did not give the client the right to revoke in writing or verbally. Client record #2 contained an informed and voluntary consent dated 6/29/12 to a government agency and an informed and voluntary consent dated 6/29/12 to his mother. The forms used as the informed and voluntary consents did not give the client the right to revoke in writing or verbally. Client record #3 contained an informed and voluntary consent dated 7/16/12 to a government agency and an informed and voluntary consent dated 7/16/12 to his adoptive parents. The forms used as the informed and voluntary consents did not give the client the right to revoke in writing or verbally. Client record #4 contained an informed and voluntary consent dated 8/21/12 to a government agency, an informed and voluntary consent dated 8/21/12 to a school, and an informed and voluntary consent dated 8/21/12 to a non-profit agency. The forms used as the informed and voluntary consents did not give the client the right to revoke in writing or verbally. Client record #5 contained an informed and voluntary consent dated 9/5/12 to a government agency, an informed and voluntary consent dated 9/5/12 to his parents, and an informed and voluntary consent dated 9/5/12 to one of the programs in the agency. The forms used as the informed and voluntary consents did not give the client the right to revoke in writing or verbally. Client record #6 contained an informed and voluntary consent dated 9/24/12 to a government agency and an informed and voluntary consent dated 9/24/12 to her mother. The forms used as the informed and voluntary consents did not give the client the right to revoke in writing or verbally. Client record #7 contained an informed and voluntary consent dated 10/17/12 to a government agency and an informed and voluntary consent dated 10/17/12 to his parents. The forms used as the informed and voluntary consents did not give the client the right to revoke in writing or verbally. The findings were confirmed during an interview with one of the clinical supervisors on December 13, 2012 at approximately 3:00 P.M.
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Plan of Correction
The project director will change the release information forms to include the provision for clients to revoke consent verbally as well as through written means. The project director will change the forms and implement with clients by 2/1/13. The project director and clinical supervisors will ensure ongoing compliance. |