INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 28 through 30, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Deefield Dual Diagnosis Lp was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection and a plan of correction is due on September 24, 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
Based on an August 28 through 30, 2007 review of employee records, the facility failed to insure that one of five employees received mandatory HIV/AIDS and TB/STD training within the required time frame, #4.
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Plan of Correction
The staff member who did not meet the requirement of having her HIV/STD and TB/STD training was unable to schedule training until 01/04 - 05/2007. It has been completed. The Clinical Supervisor will work with the training department to see that all new employees in the future receive the required training within the designated time frams per Chapter 704. |
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
Based on the facility's policy and a review of client records , the facility failed to document physical examinations within the five day time frame identified by the facility in four of five client records reviewed, #1, 2, 4 and 6. Physical examinations were conducted within seven days for clients # 1, 2 and 4. Client # 6 was in the facility for ten days at the time of the licensing inspection and had not received a physical examination.
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Plan of Correction
The Program Director has spoken with the coordinator of the CNRP to ensure that physical evaluations will be available two times a week. This will ensure that physicals occur within the time fram stated in the program policy. He will review charts to see that H&P are completed according to policy. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment services in five of five client records reviewed, #1, 2, 3, 4 and 5. Client records # 1, 2, 4 and 5 did not include the type of treatment nor frequency for either group or individual treatment. Client record # 3 did not state the type nor frequency for individual treatment services.
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Plan of Correction
The Clinical Supervisor will meet with the clinical staff and remind them that the Treatment Plan needs to include documentation that stipulates the type and frequency for group and/or individual therapy. He will review the treatment plans for the next month to ensure that they include the type and frequency of service. |