INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 16, 2008 through April 17, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Colonial House Outpatient 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 May 12, 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 on a review of personnel records, the facility failed to instruct staff in the use of fire extinguishers within the required time frame in three of three records reviewed, #2, 3 and 4. Fire extinguisher training occurred three to seven months after the date of employment.
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Plan of Correction
Currently the fire extinquisher training is completed by the inpatient staff. The Director of Outpatient shall begin to complete the training within the required time frame. This will placed on a new hire checklist designed for outpatient personnel. |
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 on a review of client records, the facility failed to document complete medication records in one of two client records reviewed, #2. The dose and frequency were missing.
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Plan of Correction
The section asks to document the amount and frequency and dosage. If a client does not have this information on them they shall be asked to call or bring in their prescription. If this does not occur then there shall be documentaion of the request made in the chart, in that section. This shall be overseen by the Director of Outpatient and begin immdiatley. Counselor was informed of the needed change in the staff meeting that followed the inspection along with a memo that was sent out the same day. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to document aftercare plans with goals with time frames in three of three client records reviewed, #4, 5 and 6. Goals were not individualized based on each clients needs and no time frames were identified.
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Plan of Correction
The Aftercare Plan will be filled out with the counselor and the client both participating and discussing the clients future goals to include the number of 12 step meetings that are reasonable for the client to attend weekly, a reasonable amount of time to speak to sponsor and support group memebers per week, a reasonable amount of time that the client must obtain employment, reasonable amount of time to pay off fines and court costs, and other individualized goals. This will be reviewed with the counslor by the Director of Operation along with the monitoring of continued compliance of the form. |