INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 20 through 21, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Western Pennsylvania Teen Challenge 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 April 14, 2008.
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Plan of Correction
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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a March 20 through 21, 2008 review of facility records, the facility failed to ensure there was at least one person trained in CPR during all hours of operation. During the month of March 2008, the schedules showed that no one was trained in CPR on the 11:00 p.m. to 7:00 a.m. shift on Sundays and Mondays.
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Plan of Correction
Arrangements were made by the program director for the gentleman who needed cpr to attend a training on 4-1-08 and he has successfully completed it. |
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 on a March 20 through 21, 2008 review of client records, the facility failed to obtain an informed and voluntary consent in one of four records, #2. Information was released to Family Court without a signed consent to release information by the client.
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Plan of Correction
The program director met with the counselor and assistant counselor on Friday 03/21/2008 and once again explained the reg. with regards to client consent to release. Both counselors understand the reg. and hopefully will not make this same mistake again. During the first 5 days of each month the program director will check all current student files to insure that consent forms are in place and signed for any information that is being released. |
709.28(d) LICENSURE Confidentiality
709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
Based on a March 20 through 21, 2008 review of client records, the facility failed to document whether or not a client was offered a copy of consent forms in one of four records reviewed, # 2. If a client is offered a consent form and accepts a copy of the form, the client signs in the space designated for this purpose. If a client is offered a copy of the consent and does not want a copy for their records, nothing is noted on consent forms. It was not clear if client #2 was offered a copy since there was nothing noted on consent forms.
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Plan of Correction
The program director met with both counsellors on 3/24/2008 and went over the reg. with regards to clients initialing consent forms as to whether they accept or reject a copy of the form. Both counsellors removed all of the forms that did not have a place on them for client initialing their acceptance or rejection of a copy of consent forms so we should be go to go with this reg being adhered to. During the first 5 working days of each month the program director will examine all of the current student files to insure that the consent forms are being initialed by clients with regards to whether they accept or reject a copy of it. |