INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 19 and 20, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Samara House of CYWA 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 September 23, 2008.
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Plan of Correction
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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of four personnel records on August 19, 2008, the facility failed to document the qualifications for the position of counselor in one of four personnel records.
Findings:
The facility did not provide documentation of one year of clinical experience in a health or human services agency for personnel record # 4.
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Plan of Correction
The facility did not provide documentation of one (1) year of clinical experience in a health or human services agency for personnel record #4._____The Clinician will be a Counselor's Aide beginning 8/22/08 and will be closely supervised by the Director. Director will sign off client files, to include Progress Reports, Tx Plans, Group Notes, Tx Plan Updates and Psychosocials, daily for Notes/weekly for all other contents. Director will also observe Counseling Sessions or Group Sessions weekly, to continue until next licensing visit. |
704.11(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
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Observations
Based on review of administrative documentation on August 20, 2008, the facility failed to develop a comprehensive staff development program for agency personnel which includes policies and procedures that indicate who is responsible and time frames for completing (1) an assessment of staff training needs, (2) an overall plan for addressing needs, (3) a mechanism to collect feedback on completed training and (4) an annual evaluation of the overall training plan.
Findings:
The facility did not indicate time frames for completing the overall training plan, and the facility did not indicate time frames for completing an annual evaluation of the overall training plan.
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Plan of Correction
The facility did not indicate time frames for completing the overall training plan, and the facility did not indicate time frames for completing an annual evaluation of the overall training plan._____Training Plan to be completed by staff annually on or before July 1. Training Plan to be approved by Director. Overall Approved Training to be completed and reviewed on or before July 31 of the following year. Annual evaluation to be completed by Director on or before July 31, staff to meet with Director for review. To begin 9/15/08 and added to Training Policy. CQI and Director to ensure compliance. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records on August 20, 2008, the facility failed to document a minimum of six hours HIV/AIDS training or at least four hours tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum in two of four personnel records.
Findings:
The facility did not document six hours of HIV/AIDS training in personnel record # 3, and the facility did not document tuberculosis, sexually transmitted diseases training in personnel record # 1.
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Plan of Correction
The facility did not document six hours of HIV/AIDS training in personnel record # 3, and the facility did not document tuberculosis, sexually transmitted diseases training in personnel record # 1._____To begin immediately, all staff to be trained in HIV/STD and TB/STD within six (6) months of hire. To be coordinated by Nurse. Personnel #3 and #1 are scheduled for missed training. Nurse to ensure all trainings are met as outlined in regulations. |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on an inspection of the facility's physical plant on August 19, 2008, the facility failed to maintain carpeting in good repair at all times.
Findings:
The facility did not maintain carpet in good condition in hallways and in bedrooms.
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Plan of Correction
The facility did not maintain carpet in good condition in hallways and in bedrooms._____Director of Housing (Maintenance) will begin to remove carpet in five (5) rooms, beginning October 1, 2008. Floors will be sanded, as they are all hardwood, and area rugs will be purchased. All rooms to be completed by June 30, 2009, five (5) rooms at a time. Director of Housing (Maintenance) to ensure completion. |
705.5 (a) (3) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(a) In each residential facility bedroom, each resident shall have the following:
(3) A storage area for clothing.
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Observations
Based on an inspection of the facility's physical plant on August 19, 2008, the facility failed to provide each client with his/her own storage area for clothing.
Findings:
The facility did not provide functioning storage areas for clothing. The facility provided chest of drawers that were broken and in poor repair.
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Plan of Correction
The facility did not provide functioning storage areas for clothing. The facility provided chest of drawers that were broken and in poor repair._____Seven (7) chests of drawers have been replaced as of 9/15/08 by maintenance. Fourteen (14) new chests of drawers to be purchased by 9/30/08. CQI and Director to ensure compliance. |
705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
Based on an inspection of the facility's physical plant on August 19, 2008,the facility failed to provide slip resistant surfaces in all bathtubs and showers.
Findings:
The facility did not provide slip resistant surfaces in three bathtubs, and one bathtub needed the slip resistant surface replaced due to wear and tear.
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Plan of Correction
The facility did not provide slip resistant surfaces in three bathtubs, and one bathtub needed the slip resistant surface replaced due to wear and tear._____Immediate - Maintenance Request given to Housing Director as of 9/15/08 to purchase and install slip resistant decals in all bathtubs and showers - five (5) bathrooms. Surfaces to be slip resistant by 9/30/08. Housing Director to ensure completion. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on an inspection of the facility's fire drill log on August 19, 2008, the facility failed to provide documentation of a fire drill conducted during sleeping hours at least once every six months.
Findings:
The facility documented only one fire drill conducted during sleeping hours for the period of November 2, 2008 through August 20, 2008.
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Plan of Correction
The facility documented only one fire drill conducted during sleeping hours for the period of November 2, 2008 through August 20, 2008._____Policy reviewed on 8/25/08 with Housing Director (Maintenance). Effective immediately, two (2) sleep hour fire drills to be conducted during a six (6) month period ongoing. CQI and Director to ensure compliance. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on a review of the facility's administrative documentation on August 20, 2008, the Project Director failed to make available to the public and annual report for the fiscal year of 2006-2007.
Findings:
The facility's annual report that was made available to the public was from the fiscal year of 2005-2006. The facility did not make the general public aware of the availability of the annual report for the fiscal year ended June 30, 2007.
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Plan of Correction
The facility's annual report that was made available to the public was from the fiscal year of 2005-2006. The facility did not make the general public aware of the availability of the annual report for the fiscal year ended June 30, 2007._____The facility will advertise December 31, 2008 the availability of the Annual Report and Audit which will include: activities and accomplishments for 2007/2008, financial statements of income and expense and names of officers, directors and principal shareholders, where applicable. Newspaper to send publication tear sheets. Executive Director to ensure compliance. |
709.26(d)(4) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(4) Salary information.
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Observations
Based on a review of four personnel records on August 19, 2008, the facility failed to document salary information that included date of employment, starting salary and all salary increases/decreases in three of four personnel records.
Findings:
The facility did not document current salary information in personnel records # 1, 2 and 4.
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Plan of Correction
The facility did not document current salary information in personnel records # 1, 2 and 4._____Director will include salary increase information in personnel records 1, 2 and 4. Director will include salary increase/decrease sheet in each personnel file and will record any changes up or down, to begin 10/1/08. Director will complete this information in all existing personnel files and update any changes, as well as any new personnel. Director is responsible for completion of salary updates.
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709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Based on a review of four personnel records on August 19, 2008, the facility failed to document at least annually an individual work performance evaluation in three of four personnel records.
Findings:
The facility did not document an annual individual work performance evaluation in personnel records, # 1, 2 and 4.
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Plan of Correction
The facility did not document an annual individual work performance evaluation in personnel records, # 1, 2 and 4. _____Director will complete all performance evaluations in all personnel records, except for Executive Director which will be done by the President of the Board of Directors. This information will be placed in the personnel files January 1 of every new year. Director is responsible to complete these evaluations.
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709.26(d)(5)(ii) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(ii) The individual shall be informed, by written copy, of their annual evaluation.
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Observations
Based on a review of four personnel records on August 19, 2008, the facility failed to document that the was informed in writing of an annual work performance evaluation in three of four personnel records.
Findings:
The facility did not provide documentation of the individual employees being informed in writing of an annual evaluation in personnel records # 1, 2 and 4.
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Plan of Correction
The facility did not provide documentation of the individual employees being informed in writing of an annual evaluation in personnel records # 1, 2 and 4._____January 1 of every year, the Director will provide a written Performance Evaluation with Directors and Staff signature. The Executive Director will be given a written Performance Evaluation by the President of the Board of Directors, which will include both signature and date. Person responsible is the Director.
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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 six client records on August 12, 2008, the facility failed to document informed and voluntary consent forms containing specific information to be disclosed in three of six client records where required.
Findings:
The facility did not provide consent forms for the release of specific information in client records # 1, 2 and 6. Information was released from client records # 1, 2 and 6 without the clients' written consent to Magellan Health Services, Department of Public Welfare, Chester County Assistance Office, Crozer-Keystone Health System, Community Care Behavioral Health Organization and Chester County Hospital.
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Plan of Correction
The facility did not provide consent forms for the release of specific information in client records # 1, 2 and 6. Information was released from client records # 1, 2 and 6 without the clients' written consent to Magellan Health Services, Department of Public Welfare, Chester County Assistance Office, Crozer-Keystone Health System, Community Care Behavioral Health Organization and Chester County Hospital._____To begin immediately, upon client admission, Counsel0or will meet with client, will review and sign necessary Consent to Release forms specific to treatment. Verbal verification to be documented in client file. No information shall be disclosed by staff until the consent is signed and reviewed. Documentation and Consent to Release information will be checked upon admission by CQI/LPN and Director to ensure compliance with Confidentiality Regulations. Bi-monthly chart reviews will be done by CQI and Director for continuity. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of six client records on August 20, 2008, the facility failed to document, in writing, notification to the client of the decision to terminate the client's treatment at the project in one of one client record where such documentation was required.
Findings:
The facility did not document notification to the client in writing to terminate treatment in client record # 5.
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Plan of Correction
The facility did not document notification to the client in writing to terminate treatment in client record # 5._____Counselor will give 72 hours written verification of termination of services to client. Verbal notification to be documented. Copy of termination to be maintained in client file, original to be reviewed and given to the client. To begin immediately. Staff trained on procedures 8/25/08. CQI and Director to ensure compliance by chart review. |
709.33(b) LICENSURE Notification of Termination
709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of six client records on August 20, 2008, one client record was required to include documentation of the client's right to request reconsideration of the facility's decision to terminate treatment. The facility failed to document the client's right to appeal the facility's decision to terminate the client in one of one record where required.
Findings:
The facility did not document the client's right to request reconsideration of the facility's decision to terminate treatment in client record # 5.
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Plan of Correction
The facility did not document the client's right to request reconsideration of the facility's decision to terminate treatment in client record # 5._____Counselor will review/document the Appeal Process with the client and allow 24 hours for written appeal to be submitted to the Director for reconsideration. A copy of the letter will be placed in the client's file, the original submitted to the Director. Termination to be considered and determined by the Director. To begin immediately, Staff was trained on 8/25/08. CQI and Director to ensre compliance by chart review. |
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
Based on a review of six client records on August 20, 2008, four client records were applicable to the residential level of care. The facility failed to document a complete psychosocial evaluation in one of four inpatient client records.
Findings:
The facility did not document an evaluation of the client's support systems, coping mechanisms, assets/strengths, negative factors that may inhibit treatment and attitude towards/ability to participate in treatment in client record #1.
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Plan of Correction
The facility did not document an evaluation of the client's support systems, coping mechanisms, assets/ strengths, negative factors that may inhibit treatment and attitude towards/ ability to participate in treatment in client record #1. _____On August 25, 2008, clinical staff and CQI staff were given a training for Outpatient and Inpatient client documentation. Psychosocial evaluation will be completed by Counselor within seven (7) days of resident's admission. Director to review and sign upon completion. Areas covered to be negative factors, assets and strengths, prognosis, participation efforts and support systems. DAP Notes to include full description of the data, assessment of the client, counselor's analysis and the plan and continuing supports. DAP Notes to be reviewed and signed off daily by Director. Director and CQI staff are responsible to ensure compliance.
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709.53(a)(5) LICENSURE Progress Notes
709.53. 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:
(5) Progress notes.
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Observations
Based on a review of six client records on August 20, 2008, four client records were applicable to the residential level of care. The facility failed to document progress notes which include data, assessment and plans relative to treatment in two of four inpatient client records.
Findings:
The facility did not document an assessment which includes the counselor's analysis of and conclusions regarding the client's current situation or status in client records # 1 and 2.
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Plan of Correction
The facility did not document an assessment which includes the counselor's analysis of and conclusions regarding the client's current situation or status in client records # 1 and 2._____On August 25, 2008, clinical staff and CQI staff were given a training for Outpatient and Inpatient client documentation. Psychosocial evaluation will be completed by Counselor within seven (7) days of resident's admission. Director to review and sign upon completion. Areas covered to be negative factors, assets and strengths, prognosis, participation efforts and support systems. DAP Notes to include full description of the data, assessment of the client, counselor's analysis and the plan and continuing supports. DAP Notes to be reviewed and signed off daily by Director. Director and CQI staff are responsible to ensure compliance.
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709.53(a)(11) LICENSURE Follow-up information
709.53. 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:
(11) Follow-up information.
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Observations
Based on a review of six client records on August 20, 2008, four client records were applicable to the residential treatment level of care. The facility failed to document follow-up information in two of four inpatient client records.
Findings:
The facility failed to document follow-up attempts in client records #s 1 and 2.
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Plan of Correction
The facility failed to document follow-up attempts in client records #s 1 and 2._____Follow-up to begin upon client's discharge. Counselor and Admissions/ Aftercare Support person to contact client seven (7) days after discharge and three (3) months thereafter. To begin immediately. Staff was trained on 8/25/08. CQI and Director to ensure compiance.
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709.54(d)(1) LICENSURE Outreach Identifying Persons
709.54. Project management services.
(d) The project shall develop a written plan providing for outreach services which includes, but is not limited to:
(1) Identifying persons in need of project services.
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Observations
Based on a review of the facility's administrative documentation on August 20, 2008, the facility failed to develop a written plan for providing outreach services which includes identifying persons in need of project services.
Findings:
The project failed to develop a written plan for identifying persons in need of their services.
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Plan of Correction
The project failed to develop a written plan for identifying persons in need of their services._____A policy has been written by the Executive Director on 9/15/08 for outreach to alert families and other persons to the availability of services. The CYWA Drug and Alcohol Department will hold an in-house training yearly for all staff members. All staff members will identify persons needing treatment and refer them to the local outpatient offices for assessments and treatment referrals. Along with the referral, staff will be given information regarding AA/NA meetings and trained to encourage people to use services including distribution of brochures and appropriate materials. Person responsible to oversee this yearly training and outreach is the Director.
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709.54(d)(2) LICENSURE Alerting Persons - Outreach
709.54. Project management services.
(d) The project shall develop a written plan providing for outreach services which includes, but is not limited to:
(2) Alerting persons and their families to the availability of project services.
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Observations
Based on a review of the facility's administrative documentation on August 20, 2008, the facility failed to develop a written plan for providing outreach services which includes alerting persons and their families to the availability of project services.
Findings:
The project did not develop a written plan for alerting persons and their families to the availability of their services.
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Plan of Correction
The project did not develop a written plan for alerting persons and their families to the availability of their services._____A policy has been written by the Executive Director on 9/15/08 for outreach to alert families and other persons to the availability of services. The CYWA Drug and Alcohol
Department will hold an in-house training yearly for all staff members. All staff members will identify persons needing treatment and refer them to the local outpatient offices for assessments and treatment referrals. Along with the referral, staff will be given information regarding AA/NA meetings and trained to encourage people to use services including distribution of brochures and appropriate materials. Person responsible to oversee this yearly training and outreach is the Director.
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709.54(d)(3) LICENSURE Encouraging Persons - Outreach
709.54. Project management services.
(d) The project shall develop a written plan providing for outreach services which includes, but is not limited to:
(3) Encouraging persons to utilize the service delivery system.
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Observations
Based on a review of the facility's administrative documentation on August 20, 2008, the facility failed to develop a written plan for providing outreach services which includes encouraging persons to utilize the service delivery system.
Findings:
The project failed to develop a written plan for encouraging persons to utilize their service delivery system.
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Plan of Correction
The project failed to develop a written plan for encouraging persons to utilize their service delivery system._____A policy has been written by the Executive Director on 9/15/08 for outreach to alert families and other persons to the availability of services. The CYWA Drug and Alcohol
Department will hold an in-house training yearly for all staff members. All staff members will identify persons needing treatment and refer them to the local outpatient offices for assessments and treatment referrals. Along with the referral, staff will be given information regarding AA/NA meetings and trained to encourage people to use services including distribution of brochures and appropriate materials. Person responsible to oversee this yearly training and outreach is the Director.
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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
Based on a review of six client records on August 20, 2008, two client records were applicable to the outpatient treatment activity. The facility failed to document a complete psychosocial evaluation in one of two outpatient records.
Findings:
The facility did not document an evaluation of the client's support systems, coping mechanisms, assets/strengths, negative factors that may inhibit treatment and attitude towards/ability to participate in treatment in client record # 6.
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Plan of Correction
The facility did not document an evaluation of the client's support systems, coping mechanisms, assets/strengths, negative factors that may inhibit treatment and attitude towards/ability to participate in treatment in client record # 6._____On August 25, 2008, clinical staff and CQI staff were given a training for Outpatient and Inpatient client documentation. Psychosocial evaluation will be completed by Counselor within seven (7) days of resident's admission. Director to review and sign upon completion. Areas covered to be negative factors, assets and strengths, prognosis, participation efforts and support systems. DAP Notes to include full description of the data, assessment of the client, counselor's analysis and the plan and continuing supports. DAP Notes to be reviewed and signed off daily by Director. Director and CQI staff are responsible to ensure compliance.
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709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on a review of six client records on August 20, 2008, two client records were applicable to the outpatient treatment activity, the facility failed to document progress notes which include data, assessment and plans relative to treatment in one of two outpatient client records.
Findings:
The facility did not document an assessment which includes the counselor's analysis of and conclusions regarding the client's current situation or status in client record # 6.
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Plan of Correction
The facility did not document an assessment which includes the counselor's analysis of and conclusions regarding the client's current situation or status in client record # 6._____In-house training on Progress Notes in the DAP format was presented on August 25, 2008 to clinical staff and LPN/CQI by the Director. Examples were given as to analysis and conclusions regarding the client's current situation or status. CQI/LPN and Director will be responsible for checking Progress Notes weekly to ensure assessments and analysis is meeting this regulation. Progress Notes to be signed off by Director, effective 8/25/08. |
709.94(f)(1) LICENSURE Project management services
709.94. Project management services.
(f) The project shall develop a written plan providing for outreach services which shall include, but not be limited to:
(1) Identifying persons in need of project services.
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Observations
Based on a review of the facility's administrative documentation on August 20, 2008, the facility failed to develop a written plan for providing outreach services which includes identifying persons in need of project services.
Findings:
The project did not develop a written plan for identifying persons in need of their services.
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Plan of Correction
The project did not develop a written plan for identifying persons in need of their services._____A policy has been written by the Executive Director on 9/15/08 for outreach to alert families and other persons to the availability of services. The CYWA Drug and Alcohol
Department will hold an in-house training yearly for all staff members. All staff members will identify persons needing treatment and refer them to the local outpatient offices for assessments and treatment referrals. Along with the referral, staff will be given information regarding AA/NA meetings and trained to encourage people to use services including distribution of brochures and appropriate materials. Person responsible to oversee this yearly training and outreach is the Director. |
709.94(f)(2) LICENSURE Project management services
709.94. Project management services.
(f) The project shall develop a written plan providing for outreach services which shall include, but not be limited to:
(2) Alerting persons and their families to the availability of project services.
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Observations
Based on a review of the facility's administrative documentation on August 20, 2008, the facility failed to develop a written plan for providing outreach services which includes alerting persons and their families to the availability of project services.
Findings:
The project did not develop a written plan for alerting persons and their families to the availability of their services.
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Plan of Correction
The project did not develop a written plan for alerting persons and their families to the availability of their services._____A policy has been written by the Executive Director on 9/15/08 for outreach to alert families and other persons to the availability of services. The CYWA Drug and Alcohol Department will hold an in-house training yearly for all staff members. All staff members will identify persons needing treatment and refer them to the local outpatient offices for assessments and treatment referrals. Along with the referral, staff will be given information regarding AA/NA meetings and trained to encourage people to use services including distribution of brochures and appropriate materials. Person responsible to oversee this yearly training and outreach is the Director. |
709.94(f)(3) LICENSURE Project management services
709.94. Project management services.
(f) The project shall develop a written plan providing for outreach services which shall include, but not be limited to:
(3) Encouraging persons to utilize the service delivery system.
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Observations
Based on a review of the facility's administrative documentation on August 20, 2008, the facility failed to develop a written plan for providing outreach services which includes encouraging persons to utilize the service delivery system.
Findings:
The project failed to develop a written plan for encouraging persons to utilize their service delivery system.
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Plan of Correction
The project failed to develop a written plan for encouraging persons to utilize their service delivery system._____A policy has been written by the Executive Director on 9/15/08 for outreach to alert families and other persons to the availability of services. The CYWA Drug and Alcohol Department will hold an in-house training yearly for all staff members. All staff members will identify persons needing treatment and refer them to the local outpatient offices for assessments and treatment referrals. Along with the referral, staff will be given information regarding AA/NA meetings and trained to encourage people to use services including distribution of brochures and appropriate materials. Person responsible to oversee this yearly training and outreach is the Director. |