INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 26 & 27, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Cen-Clear Child Services, Inc. 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 July 28, 2008.
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Plan of Correction
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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
Based upon a review of six personnel records on June 26, 2008, the facility failed to ensure that all staff were instructed in the use of the fire extinguisher within seven days of employment.
Two out of six staff records reviewed, #3 & 5, showed that the staff were not trained within seven days from their hire date. Employee #3 was hired on 4/7/08 and had not received the training until 4/24/08. Employee #5 was hired on 1/28/08 and had not received the training until 2/11/08.
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Plan of Correction
We have changed our orientation day of hire to include the fire extinguisher training as part of the day. This orientation is done by the project director at the Two Roads site on first day of hire for each new employee. |
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
Based upon a review of six personnel records on June 26, 2008, the facility failed to ensure that all staff were trained to perform assigned tasks during emergencies within seven days of employment.
Two out of six staff records reviewed, #3 & 5, showed that the staff were not trained within seven days of their hire date. Employee #3 was hired on 4/7/08 and had not received the training until 4/24/08. Employee #5 was hired on 1/28/08 and had not received the training until 2/11/08.
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Plan of Correction
This training will occur during orientation day for staff. Project Director is responsible to review the procedure upon hire date. This will be monitored by the coordinator and as part of new hire employee check list of discussions that occur at the first day of hire of the employee. In addition, the project director will review with all new hires as part of their initial supervision and orientation to CCS's Two Roads. They will be signing off that they reviewed the evacuation procedure specific the Two Roads site. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based upon a review of the fire drill records on June 27, 2008, the facility failed to maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
The facility failed to document the time that the fire drill occurred from January 2008 to present.
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Plan of Correction
Facility will document the time the fire drill occured in future reports. The program director is responsible to review the fire drill log and make sure it is complete and contains correct/completed information. The program director will review logs for 4 months for compliance. If at the end of that period of time the facility remains in compliance, the program director will review the fire drill log at random intervals for compliance. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based upon a review of the fire drill records on June 27, 2008, the facility failed to alternate exits during fire drills.
All fire drills from November 2007 to present indicated that the facility was consistently utilizing both the front and back exits.
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Plan of Correction
The program director will utilize and document the use of alternative exits for fire drills. This will be documented on the fire drill log which has added which exit was utilized on a specific drill. Program director is responsible to review the log monthly to ensure compliance for a period of 4 months, there after random reviews will occur for compliance. |
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
Based upon a review of the facility's annual report on June 27, 2008 for the August 2006-July 2007 period, the facility failed to include facility expenses for any of the departments, nor the facility as a whole and the annual report did not include revenues for the D&A department.
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Plan of Correction
The CCS's, Two Roads annual board report for fiscal year July 07 to July 08 was not due when liscensure occured. The Assitant to the Executive Director will be responsible to include in this years annual board report to include the fiscal outcomes of the DA division annually. The facility director will report the fiscal piece to the Assistance to incorporate into the CCS annual report. The annual board report is deseminated to Facility Director prior to finalization. |
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
Based upon a review of the facility's annual report on June 27, 2008, for the August 2006-
July 2007 period, the facility failed to list the names of the officers and directors of the board.
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Plan of Correction
Assistant to the Executive Director is responsible to compile to CCS annual board report that is due 9/08. The assistanct to the ED, is responsible to add a section to the annual board report to include the names and potions of the board of CCS. This will be reviewed with the Facility Director of the DA division. |
709.26(f) LICENSURE Personnel Management
709.26. Personnel management.
(f) There shall be written job descriptions for project positions which include, but are not limited to:
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Observations
Based upon a review of six personnel records on June 26, 2008 the facility failed to provide written job descriptions for project positions in two of six personnel records reviewed.
Personnel records #3 & 4 contained job descriptions that had not been signed by the staff and the job descriptions were for the mental health counselor rather than the drug and alcohol counselor position.
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Plan of Correction
Personal # 3 and #4 have resigned from their positioins with CCS. New staff hires in July have updated and completed Job Descriptions appropriate to the DA division of CCS. The facility director updated new job descriptions that are specific to DA division of CCS. The human resource coordinator will be responsible to get current job descriptions of all employees at time of orientation day which is the first day of hire. The orientation check list incorporates the job description. Facility director will be responsible to follow through with checking with the HR cooridinator that current job descriptions are part of the personal file. |
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
Based upon a review of four client records on June 27, 2008, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in four of four client records reviewed.
Client records #1-4 did not allow for the verbal revocation of the consent.
Client record #1 lacked a consent to release information to the client's parents; however the June 18, 2008 progress note indicated that the client's parent participated in the session.
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Plan of Correction
Chart reviews will be conducted on biweekly basis by departmental assistant and deficiencies noted for any missing/incorrect information or forms and given to the project director. During staff supervision, the project director will review these deficiencies with the staff to ensure the deficiencies have been corrected and all appropriate forms/consents have been obtained and completed.
Release of Information forms were added to intake/opening packets and have been updated to include "this consent can be revoked at any time". |
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
Based upon a review of four client records on June 27, 2008, the facility failed to complete the
biopsychosocial evaluations at intake, in accordance with their policy and procedures, in 4 of
4 client records reviewed.
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Plan of Correction
The Facility Director with the approval of board of governors have updated CCS policy and procedure on July 08 to allow 30 days after admission to complete the biopsychosocial evaluation. Program director will be responsible to ensure that these evaluations are completed within the 30 days of admission. Biweekly chart deficiency reviews will occur by the dept. assistance as well to ensure timelines are being met. |
709.93(a)(2) 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:
(2) Medication records.
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Observations
Based upon a review of four client records on June 27, 2008, two client records required documentation of medications. The facility failed to properly document the dosage of the medications in two of two client records reviewed, specifically #1 & 3.
Client record #1 simply stated, "1 shot every three months" and client record #3 simply stated, "1 pill per day."
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Plan of Correction
Project Director will train staff in completing necessary paperwork in a complete fashion. Staff will be trained and given example completed forms etc, by the program director within the first three days of hire. Chart reviews will be conducted by program director on biweekly basis, on going oversite of completed forms, deadlines etc will be monitored by Project Director through these chart reviews. If after 4 months of compliant reviews, the staff charts reviews will be conducted at random intervals for compliance/completion by the project director. |