INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 17, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Treatment Trends Inc. Confront 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 February 18, 2008.
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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 facility policy and training records, the facility failed to document training plans according to Treatment Trends Inc. policy in eight of nine employee records reviewed, # 2, 3, 4, 5, 6, 7 and 8. Training plans were not documented within the required time frame.
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Plan of Correction
Confront was not in compliance with 704.11 due to many new and part-time fee for service staff that were newly hired in 2007. New staff were given an opportunity to submit certificates that document trainings already completed and that meet BDAP standards. Newly hired staff will have an initial training plan developed as part of their orientation process and the Program Director or Clinical Supervisor will ensure this will occur within 30 days. This plan of correction will be immediately implemented. Current staff will give input and work on the development of their own training plan(s) during the review process of their annual performance evaluation. |
709.93(a)(3) 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:
(3) Record of services provided.
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Observations
Based on a January 17, 2008 review of client records, the facility failed to document a complete record of services in eight of eight client records reviewed, # 1, 2, 3, 4, 5, 6, 7 and 8. The provider of service was not documented.
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Plan of Correction
Due to an administrative oversight, the name of the person that provided the client service was omitted from the service record in the front of each client's file. This was inadvertently missing as we had previously recorded the counselor's name as well as had each service personally initialed. We stopped the initials due to the number of part time counselors and the time involved to pass around all client service records to all providers.
The Program Director will work with the administrative staff to put the name of each counselor who provided the individual and/or group service on every client record. This will be done immediately, and be reflected on all client service records starting with the month of January 2008. |