INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 29-30, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Crisis Management 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 November 5, 2008.
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Plan of Correction
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of six personnel records on September 29, 2008, the facility failed to document a complete individual training plan in six of six personnel records.
Findings:
The facility did not document an individual training plan to include potential resources for the identified training subject listed in training plans in personnel records #s 1, 2, 3, 4, 5 and 6.
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Plan of Correction
The Facilities Director will redesign the staff development Program so that each individual training plan will include potential resources for the identified training subject listed training plan |
705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
Based on an inspection of the facility ' s physical plant on September 30, 2008, the facility failed to provide slip-resistant surfaces in all bathtubs/showers.
Findings:
The facility did not provide slip-resistant surfaces in four of eight client bathtubs/showers.
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Plan of Correction
The Facilities Director will work with the Director of Management Services to insure that new slip resistant surfaces are installed in each of the bathtubs/showers in the River's Bend Program. The bathtub/shower areas will be inspected on a regular basis to insure that the slip resistant surfaces are still in place and usable. |
709.52(a)(3) LICENSURE Support service type
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:
(3) Proposed type of support service.
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Observations
Based on a review of five personnel records on September 30, 2008, the facility failed to document a complete individual treatment and rehabilitation plan in five of five client records.
Findings:
The facility did not document an individual and treatment and rehabilitation plan to include proposed types of support services in client records #s 1, 2, 3, 4 and 5.
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Plan of Correction
The Facilities Director will re-design the individual treatment and rehabilitation plan so that it will include a section that clearly includes proposed types of support services. The Facilities Director will re-educate the Primary Therapist to insure that these proposed supportive services are incorporated into each treatment plan. |