INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 27 and September 28, 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 26, 2006.
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Plan of Correction
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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
The organization failed to provide or document the general training requirements for one support staff within two years of employment.
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Plan of Correction
The agency was and continues to be under financial constraints thus not providing the funds for the one support staff to complete her general training requirements in two years. In addition the unavailability of trainings in the North West part of PA makes it highly impossible as well to comply and being under financial constraints makes it even more difficult to pay for mileage and hotel stays in the eastern part of PA where the majority of the general training classes are held. The one support staff will attend TB/STD and other health related issues on January 16, 2007 in Carlisle, PA. There is training sooner, however, the one support staff has a medical condition that prevents her from attending any time sooner. The office manager and the supervisor of the drug and alcohol program will ensure the one support staff complies as well as the other support staff complies with the general training requirements within two years of employment. |
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
The organization failed to provide or arrange for CPR and first aid training for a sufficient number of staff to cover all hours of operation.
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Plan of Correction
The administrative staff came to a decision that one staff member was sufficient to be certified in CPR and First Aid since we only had one full time counselor and very limited part time counselor to cover the hours of business. However, a support staff person will be attending a First Aid and CPR training on November 7, 2006 in Erie, PA at the American Red Cross. The Office Manager and supervisor of the drug and alcohol program will ensure the staff person attends and that we consistently have two people certified. |
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
The governing body failed to make available to the public an annual report.
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Plan of Correction
The facility was not in compliance in making available to the public an annual report because of financial constraints ? the expense of publishing and mailing of the newsletter with the annual report. October 31, 2006, the facility will be releasing its annual report. The Executive Director and Supervisor of the Drug and Alcohol Program will ensure the annual report is published and released now and every year in April. |
709.22(e)(1) 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:
(1) Activities and accomplishments of the preceding year.
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Observations
The governing body failed to provide an annual report which includes activities and accomplishment of the preceding year.
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Plan of Correction
The facility was not in compliance in making available to the public an annual report with activities and accomplishments of the agency of the preceding year because of financial constraints ? the expense of publishing and mailing of the newsletter with the annual report. October 31, 2006, the facility will be releasing its annual report which includes the activities and accomplishments of the preceding year. The Executive Director and Supervisor of the Drug and Alcohol Program will ensure the annual report is published and released with activities and accomplishments of the preceding year now and every year. |
709.22(e)(2) 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:
(2) A financial statement of income and expenses.
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Observations
The governing body failed to provide an annual report with a financial statement of income and expenses.
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Plan of Correction
The facility was not in compliance in making available to the public an annual report with a financial statement of income and expenses because of financial constraints ? the expense of publishing and mailing of the newsletter with the annual report. October 31, 2006, the facility will be releasing its annual report which includes a financial statement of income and expenses. The Executive Director and Supervisor of the Drug and Alcohol Program will ensure the annual report is published and released with a financial statement of income and expenses now and every year. |
709.22(e)(3) 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:
(3) A statement disclosing the names of officers, directors and principal shareholders, where applicable.
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Observations
The governing body failed to provide an annual report with a statement disclosing the names of officers, directors and/or principal shareholders.
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Plan of Correction
The facility was not in compliance in making available to the public an annual report with a statement disclosing the names of officers, directors and/or principal shareholders because of financial constraints ? the expense of publishing and mailing of the newsletter with the annual report. October 31, 2006, the facility will be releasing its annual report which includes a statement disclosing the names of officers, directors and/or principal shareholders. The Executive Director and Supervisor of the Drug and Alcohol Program will ensure the annual report is published and released with a statement disclosing the names of officers, directors and/or principal shareholders now and every year. |
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
The project failed to obtain a letter of agreement for 24- hour emergency medical coverage
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Plan of Correction
A letter of agreement for 24 hour emergency medical coverage was not obtained due to an oversight when we mailed it in April 2006 because the previous letter of agreement with Warren General Hospital contained the coverage. A new letter of agreement was sent on October 17, 2006 to Warren General Hospital seeking agreement for 24 hour emergency medical coverage for our clients. The Supervisor of the Drug and Alcohol Program will ensure a written agreement of 24 hour medical coverage is always obtained during renewal times. |
709.26(e) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
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Observations
The project director failed to demonstrate the projects efforts toward informing the staff of rights.
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Plan of Correction
The project director failed to inform the staff of their rights in our personnel section of the SAS Program Manual due to an administrative oversight when the project revised the entire personnel section of the manual. On October 10, 2006, the Office Manager in collaboration with the Supervisor of the Drug and Alcohol Program revised the personnel manual to include informing the staff of their rights. Supervisor of the Drug and Alcohol Program in collaboration with the Office Manager will ensure the staff is always informed of their rights. |
709.26(e)(2) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
(2) The employe's right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records.
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Observations
The project director failed to develop organizational policies in regard to the employees's right to request correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records.
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Plan of Correction
The project director failed to inform the staff of their rights in our personnel section of the SAS Program Manual to request correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records due to an administrative oversight when the project revised the entire personnel section of the manual. On October 10, 2006, the Office Manager in collaboration with the Supervisor of the Drug and Alcohol Program revised the personnel manual to include the employee's rights to request correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records. Supervisor of the Drug and Alcohol Program in collaboration with the Office Manager will ensure the staff is always informed of their right to request correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records. |
709.26(e)(3) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
(3) The employe's right to submit rebuttal data or memoranda to his own records.
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Observations
The project director failed to develop organizational policies in regard to the employ's right to submit rebuttal data or memoranda to his records.
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Plan of Correction
The project director failed to inform the staff of their rights in our personnel section of the SAS Program Manual to submit rebuttal data or memoranda to his/her records due to an administrative oversight when the project revised the entire personnel section of the manual. On October 10, 2006, the Office Manager in collaboration with the Supervisor of the Drug and Alcohol Program revised the personnel manual to include the employee's rights to submit rebuttal data or memoranda to his/her records. Supervisor of the Drug and Alcohol Program in collaboration with the Office Manager will ensure the staff is always informed of their right to submit rebuttal data or memoranda to his/her records. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
The facility failed to document follow-up attempts in the client records.
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Plan of Correction
The facility failed to document follow up attempts in the client records because of a lack of diligent attention to the regulation by the Supervisor of the Drug and Alcohol Program and counselors. On October 9, 2006, the Supervisor of the Drug and Alcohol Program informed the counselors of their responsibility to document follow-up attempts with clients in their record for referrals and after being discharged. In addition, the project changed its policy in following-up with clients to 30 days after discharge rather then 6 months and a year to facilitate better compliance and tracking. The Supervisor of the Drug and Alcohol Program and counselors will need ensure ongoing documentation. |