INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 19 - 20, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Family A.C.T.S. Incorporated 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.
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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 a review of personnel records, the facility failed to document HIV/AIDS training in one of two personnel records.
The findings include:
Six personnel records were reviewed on June 19, 2012. Two personnel records were reviewed for documentation of HIV/AIDS training. The facility failed to document the required HIV/AIDS training in personnel record # 6.
Employee # 6 is support staff and was hired August 20, 2009. HIV/AIDS training was due to be completed no later than August 20, 2011. The facility failed to provide documentation of HIV/AIDS training for employee # 6 as of June 19 - 20, 2012.
The project/facility director was interviewed and confirmed the findings.
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Plan of Correction
Project/Facility director will ensure that all future staff, including support staff complete required training(s) in appropriate time frames and provide documentation in personnel files. This will be accomplished through the development of a checklist hilighting the required trainings and time frames for each employee respectively. The project/facility director has scheduled employee #6 for HIV/AIDS training on Wednesday, July 11, 2012 and upon completion will submit documentation to the employees personnel file. |
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 on a review of client records, the facility failed to document a psychosocial evaluation that included a clinical assessment of the client in six of six client records.
The findings include:
Eleven client records were reviewed on June 19 - 20, 2012. Six client records were required to document a psychosocial evaluation. The psychosocial evaluations did not include a clinical assessment of the client and only included client reported historical information in client records # 6, 7, 8, 9, 10 and 11.
Client # 6 was admitted into treatment on November 22, 2011. The psychosocial evaluation was completed on November 22, 2011. The psychosocial evaluation did not include a clinical assessment of the client and only included client reported historical information.
Client # 7 was admitted into treatment on April 18, 2012. The psychosocial evaluation was completed on April 18, 2012. The psychosocial evaluation did not include a clinical assessment of the client and only included client reported historical information.
Client # 8 was admitted into treatment on May 21, 2012. The psychosocial evaluation was completed on May 21, 2012. The psychosocial evaluation did not include a clinical assessment of the client and only included client reported historical information.
Client # 9 was admitted into treatment on November 30, 2011. The psychosocial evaluation was completed on November 30, 2011. The psychosocial evaluation did not include a clinical assessment of the client and only included client reported historical information.
Client # 10 was admitted into treatment on February 7, 2012. The psychosocial evaluation was completed on February 7, 2012. The psychosocial evaluation did not include a clinical assessment of the client and only included client reported historical information.
Client # 11 was admitted into treatment on January 11, 2012. The psychosocial evaluation was completed on January 11, 2012. The psychosocial evaluation did not include a clinical assessment of the client and only included client reported historical information.
The project/facility director was interviewed throughout the licensing inspection and confirmed the findings.
This is a repeat citation from the June 6 - 7, 2011 licensing inspection.
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Plan of Correction
The project/facility director will ensure that all psychosocial evaluations include a clinical assessment (clinical opinion) of the client effective 06/28/2012. This will be accomplished through reviewing the psychosocial evaluations and varifying a clinical assessment has been provided in the records of all new clients. These reviews will take place during weekly supervision and/or weekly staff meetings. |