INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 9, 10 and 11, 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 12, 2007.
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Plan of Correction
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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
A review of four training files documented that the project failed to provide CPR certification and first aid training for a sufficient number of staff to cover all hours of operation.
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Plan of Correction
The site did not have updated first aid training, most all staff had expired dates on the last first aid training attended. Two staff (one day shift/one eveing shift)from the Paoli site will register & complete a current first aid training within the next three months at local YMCA. The site director will ensure staff complete training within stated time frames. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
In one of four training files reviewed on May 10, 2007, the project failed to provide or document 25 hours of training for the previous training year. In employee record number 2, the project failed to document 25 hours of training for the 2006 training year.
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Plan of Correction
Employee #2 was short of required hours in 2006 by 6 hours. The site director has met with the employee as of 5/18/07 and informed of deficiency. The employee already has met 19 hours of 2007 required 25 hours. The site director will track progress on a quarterly basis during staff meetings. The Paoli site has an additional in-house 10 hours of this required training available & employee #2 has enrolled & should exceed 2007 educational requirments by year's end. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
A review of employee file number 1, 3 and 5, on May 10, 2007, failed to include documentation of fire extinguisher instruction within seven days of employment.
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Plan of Correction
The employees did not have orientation documentation of fire extinguisher instruction completed & put in their personel files within 7 days of hire date. The site director will orient all three employees on "How to use Site Fire Extinguishers" & have each sign off that this instruction was completed by 6/21/2007. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
A review of employee file number 1, 3 and 5, on May 10, 2007, failed to include documentation of training within seven days of employment for tasks to be performed in an emergency.
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Plan of Correction
Employees did not have documnetation of emergency procedures documented in their personel file within 7 days of their hire date. The site director - Tom Connell will complete training with each of these employees on 6/21/2007 and have them sign off that they are aware of these procedures. the sign off sheet will be placed in each personel file at Paoli office. |
709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
The project director failed to establish project goals and objectives with time frames and available resources. A review of governing body information, to include board meeting minutes and quarterly reports, failed to include the necessary documentation.
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Plan of Correction
Tom Whiteman, president, stated project goals and included in the governing body minutes, but without specific goals and time frames included in the report. Tom Whiteman & Susan Mackey will write down specific objectives with quarterly time frames reported/included by 6/21/2007. These will also be documented & included in the 2007 Governing Body report after approval from Governing Body by 6/30/2007. |
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
A review of the organizations treatment management plan and letters of agreement failed to document an agreement for 24 - hour emergency medical coverage.
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Plan of Correction
A letter of agreement with Main Line Health Hospitals was current but did not include the wording - 24 hour medical emergency coverage in the documentation. A revised referral agreement with wording specific to include 24 hour emergency medical coverage will be sent out by 5/25/2007. Tom Connell, Site Director of Paoli will monitor progress on this monthly & place in the current referral agreement log when it is recieved at the facility. |
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
A review of three of four personnel files on May 10, 2007 revealed that the project failed to provide documentation of the projects efforts toward informing employees number 1, 3 and 4 of employee rights.
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Plan of Correction
Employee rights are included during the orientation period and placedin the personel files of each new employee;three files at Paoli did not include this documentation. Tom Connell, site director of Paoli will meet with each employee affected, review employee rights stated in our manual, and have each employee sign off that this was completed. This documentation will be placed in their personel files at the Paoli site by 6/21/2007. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
A psychosocial evaluation was missing from client record # 5, which was one of five client records reviewed.
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Plan of Correction
A psychosocial evaluation was not completed by the therapist of record. Tom Connell, site director of Paoli has met with the therapist as of 5/18/2007. A hour long, individualized training was completed with this therapist on 5/18/2007 from 2 pm to 3 pm. Random charts will be selected on a monthly basis from this therapist's case load starting on 6/30/2007. This process will be completed on a monthly basis to ensure the therapist is in compliance with the standard. Any future deficiencies will result in written disciplinary action against the therapist. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
An individual treatment and rehabilitation plan was missing from client record number 5, which was one of five client charts reviewed on May 11, 2007.
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Plan of Correction
A treatment plan was not completed by the therapist of record on this chart. Tom Connell, site director of paoli office, completed a one hour, individual training from 2 pm to 3 pm on "Treatment Planning" with therapist of record. Random charts will be audited from this therapist's case load beginning 6/30/2007. This procedure will continue on a monthly basis until the therapist is in compliance. Any future deficiencies in this area will result in written, disciplinary action with the therapist. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
One of five client records reviewed, client number 2, failed to provide documentation of case consultation notes.
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Plan of Correction
Since the chart that failed to meet the standard was completed by the Site director. The site director, Tom Connell, will review the standard on case consults & sign off that he understands this component of treatment. The site director will ensure that he is incompliance with the standard by 6/15/2007. |