INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 23 through 27, 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 June 1, 2007.
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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
Employee #10 lacked documentation to verify that he/she completed the mandatory six hours of HIV/AIDS training within two years of his/her date of hire with the facility.
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Plan of Correction
The Director of Administrative Services has contracted with Berks Aids Network/Co-County Wellness Services to provide trainings throughout the year to ensure that staff shall receive a minimun of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD training. Employee #10 is scheduled to attend the next available training scheduled for June 2007. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Vital signs for clients in five of five records reviewed were incomplete. Client records 1, 2, 4 & 5 lacked documented temperatures and client record #3 lacked any vital signs.
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Plan of Correction
The Director of Administrative Services met with ADAPPT's contracted physician and discussed the deficiences found in the client records. Effective May 17, 2007 the physician indicated that the necessary information will be documented on all client records. The Services Coordinator will check on a weekly basis that all necessary information has been documented. |
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
Problems/needs were not documented in three of five client records reviewed, #2, 4 & 5.
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Plan of Correction
The Clinical Supervisor held a training for clinical staff on May 18, 2007 and reviewed the mandatory information outlined in the Psycosocial Evaluation. Going forward from that date, all Psychosocial evaluations will contain information relating to the client's assets, liabilities, coping skills, and support systems as required according to BDAP regulations.
The Clinical Supervisor will ensure compliance with this plan of correction by on-going reviews of client files. |
709.52(e)(3) LICENSURE Legal support services
709.52. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(3) Legal.
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Observations
The facility lacked a letter of agreement for supportive services for legal assistance and was not able to provide other documentation demonstrating the ability to assist the client in obtaining such support services.
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Plan of Correction
The Director of Administrative Services has obtained a written provider agreement with the Berks County Bar Association Lawyer Referral Service.
The Director of Administrative Services will ensure that this agreement is updated as mandated by BDAP, and on file for client's use. |
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 consults were not completed for two of four clients, #1 & 2.
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Plan of Correction
Training for clinical staff was held on May 21, 2007 to review the mandatory information contained in client files concerning Case Consultations. All client charts will now contain at least one Case Consultation according to ADAPPT policies and procedures.
On-going supervision related to this plan of correction will be done by the Clinical Supervisor. |