INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 16, 2007 through April 18, 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 May 15, 2007.
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Plan of Correction
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704.11(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
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Observations
The policies and procedures for the staff development plan did not include the timeframe for the completion of the overall training plan or how and when the annual evaluation of the prior training year is to be completed.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
The female client's lavatory on the first floor has an exhaust fan that is not operable.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.92(c)(1) LICENSURE TX Plan Goals
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(1) Short and long-term goals for treatment, as formulated by both staff and client.
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Observations
Treatment plans goals were not stated in terms of measurable criteria, or contained only disciplinary actions if the client were to fail to meet their goals in nine of fourteen client records reviewed, # 2, 3, 4, 5, 6, 8, 9, 12 and 13.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.92(c)(3) LICENSURE Support Service
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
The proposed support services in the comprehensive treatment plans were either left blank, were identified as "none", or only identified the treatment program in six of fourteen client records reviewed, # 6, 8, 9, 11, 13 and 14.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.92(d) LICENSURE Tx Plan Update
711.92. Treatment and rehabilitation services.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Treatment plan updates did not provide a review of progress on previously stated goals in eight of thirteen client records reviewed, # 1, 2, 3, 5, 7, 8, 12 and 13.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.93(c)(1)(i) LICENSURE Confidentiality - Client Identity/Records
711.93. Client records.
(c) Confidentiality.
(1) A written procedure shall be developed by the project director which complies with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(i) Confidentiality of client identity and records.
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Observations
Thomas Jefferson University hospital confidentiality procedures allow for the release of client information without consent in all instances of abuse, neglect, and domestic violence. This is not consistent with state and federal confidentiality laws.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |