INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on April 10, 2006 to April 13, 2006 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 19, 2006.
|
Plan of Correction
|
705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
|
Observations
The hot water tested at 130 degrees. Hot water temperature may not exceed 120 degrees Fahrenheit.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
705.25 (3) LICENSURE Food service.
705.25. Food service.
A nonresidential facility may provide meals to clients through onsite food preparation areas, a central food preparation area or contractual arrangements with vendors or caterers. A nonresidential facility which operates an onsite food preparation area or a central food preparation area shall:
(3) Clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
|
Observations
The eating utensils were not stored in an enclosed area.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
|
Observations
The fire extinguishers were last inspected in January 2005. Fire extinguishers must be inspected and approved annually by the local fire department or fire extinguisher company.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
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.
|
Observations
Employee number 7 was provided instruction 10 days from the date of employment and employee 9 was provided instruction 13 days from the date of hire.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
|
Observations
Client records A, B, and F failed to include consistent documentation of twice weekly individual counseling sessions.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
709.83(a)(4) LICENSURE Client records
709.83. 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:
(4) Case consultation notes.
|
Observations
Client records C and G failed to document case consultations.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
709.83(a)(5) LICENSURE Client records
709.83. 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:
(5) Medication records.
|
Observations
Client records C, F, and G did not include the dose and frequency of medication.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
709.83(a)(11) LICENSURE Client records
709.83. 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:
(11) Follow-up information.
|
Observations
Client records C, D, G, and H did not include documentation of follow up as per the agency's policy.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
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:
|
Observations
The "Consent to Use and Disclose Health Information" form contains a general consent to release information. The client gives Zoar "consent to the use and disclosure of my protected health information ..." The form identifies that information can be shared with various health care professionals, health insurance companies or plans, and direct care clinicians. General consents are not permitted as they do not meet the requirements of 42 CFR Part 2 Subpart C subsection 2.31 or 28 Pa. Code subsection 709.28(c)(1)-(6).
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |