INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on July 23, 2007 and July 24, 2007 1, 2007 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 August 17, 2007.
|
Plan of Correction
|
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.
|
Observations
The project director failed to ensure a sufficient number of staff are trained in CPR and first aid. A review of staff development files on 07/23/2007 verified the number of persons trained are not sufficient for the hours of operation.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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:
|
Observations
The governing body failed to insure the annual report is available for public review within six months of the fiscal year end. The annual report for the fiscal year 2005/2006 was not available to the public until March 2007.
|
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.
|
Observations
The project director failed to protect client information. Three of eight client records reviewed on July 24, 2007 documented release of client information including, client assessment information, for funding determination to the Montgomery case management unit. These releases of information exceeded the limitations imposed at 4 Pa. Code Subsection 255.5(b). Client record numbers 5, 6 and 12.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |