INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 16, 2006 to May 20, 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 June 15, 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
Mandatory communicable disease training was not consistently documented. Records # 2 and 9 did not have documentation of the required training.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Counseling room doors have windows which were not covered and consequently permitted counseling sessions to be seen outside the counseling room.
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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:
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Observations
The annual report was not made available to the public in a timely manner . Documentation must occur within six months of the end of the fiscal year. The 2004-2005 annual report was not made available until January 10, 2006.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.24(a)(2) 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:
(2) Treatment models utilized by the project.
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Observations
Treatment models used by the project should be specified and defined in the policy manual. Treatment models used did not include definitions.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
The audit must be completed within six months of the end of the fiscal year. The 04-05 audit was not done until April , 2006 or 10 months beyond the end of the fiscal year.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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
Each file reviewed contained a consent to release information form attached to the client sign off on the HIPAA requirements. This form was not completed in accordance with applicable laws in any of the records reviewed, and consequently , did not meet the requirements for an informed consent.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.30(1) LICENSURE Client Rights
709.30. Client rights.
(1) A person receiving care or treatment under section 7 of the act (71 P. S. 1690.107), shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Client rights violations were noted in conjunction with the administration of the behavior modification point system used . Clients are denied family visits based on the number of points/demerits accrued during the course of a typical week. Clients may not be denied family contact exclusively on the basis of an arbitrarily established point system .
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.32(c)(1) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication.
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Observations
The agency medication administration policy states that clients are to report for their prescribed medications at specified times. If clients do not report at the times specified, they do not receive their medications . The only exceptions are PRN medications and diabetic medications. The agency is responsible to ensure that clients comply with prescribed medication regimens as ordered. Where clients are uncooperative with the physician's orders, appropriate follow up action should be taken by the agency relative to contacting the physician, providing appropriate counseling and clearly documenting the events.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.32(c)(4) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(4) Methods for control and accountability of drugs.
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Observations
Methods for control and accountability of client medications do not efficiently track medication start dates, stop dates, missing medications identified by inventory and the observed self administration of medications as prescribed by the physician. The policy should indicate who is authorized to remove drugs from the storage area and the means of accountability for all stored drugs. Documentation in medication logs should include the reasons clients did not receive their medications at the prescribed frequency or dose.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.32(c)(7) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(7) Medication errors and drug reactions.
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Observations
The system for tracking medication errors did not give an indication of what the error was, why it occurred, or what was done to rectify the situation. The agency policy was not followed as regarded notifying the prescribing physician, and following the stipulated reporting procedure.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.53(a) LICENSURE Complete Client Record
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:
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Observations
Client records were incomplete as regarded the tracking of client medications, documentation of medication errors and follow up medical appointments and counseling for clients who were apparently resistive to using medications as prescribed.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.53(a)(2) LICENSURE Medication records
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:
(2) Medication records.
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Observations
Medication records were incomplete in the files reviewed and in the medication sign off logs which become a part of the client file.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.53(a)(8) LICENSURE Case Consultation 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:
(8) Case consultation notes.
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Observations
Case consultation notes were generally timely but did not consistently include two clinical staff. Where a multi-disciplinary staff does not exist, case consultations should include the primary counselor and one other clinician. Records # 2, 4, 6 and 8 contained the signatures of one clinical staff and one support staff on case consultations.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Work therapy goals were generic in nature. Goals should be individualized to meet the specific assessed needs of each client.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |