INITIAL COMMENTS
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This is an on site licensure renewal inspection conducted on March 10, 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. .
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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
An individual training plan must be documented for each employee annually. Plans should be documented for new employees within the first month of hire. No plans were noted for student interns.
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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 |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Each counselor, whether full or part time, must meet the minimum annual training requirement of 25 hours. File # 66 did not meet the requirement.
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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 |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Fire alarms are not routinely set off at the time fire drills are conducted. An alternate procedure is used to alert building occupants of the fire drill. No documentation was presented to demonstrate that the alternate procedure had been approved by the Division.
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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 |
709.81(b)(3)(ii) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Drug and alcohol histories in records reviewed did not provide a complete picture of the client's drug use patterns. Incomplete histories were noted in the following records: #1, 2, 6 and 7.
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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 |
709.81(b)(3)(iii) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Personal histories must be constructed to collect as much information about the client as possible. Histories were incomplete. They generally lacked detail and frequently did not address all areas required by this regulation. Personal histories were missing or incomplete in the following records: #1, 2, 3, 6 and 7.
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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 |
709.83(a)(10) 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:
(10) Discharge summary.
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Observations
Discharge summaries did not consistently address all areas required. Incomplete discharge summaries were noted in the following records: # 3.
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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 |
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.
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Observations
Follow up must be documented in accordance with agency policy. Documentation of follow up was not done for each client. Follow up was not documented for all types of discharges. A minimum of one follow up contact must occur for each type of discharge.
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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 |
709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
An employee probationary evaluation was missed in one of one applicable files for this site (File #66).
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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 |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Record storage was not being done in accordance with the stipulation of the Licensing alert dated November 2004. The record storage room must be staffed or locked at all times. During the course of the inspection it was determined that the room is not staffed and that the door is not locked at all times throughout the day.
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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 |
709.28(c)(2) 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:
(2) Specific information disclosed.
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Observations
Information released to entities addressed under the requirements of 4 PA Code subsection 255.5(b) exceeded the parameters. Examples of this were noted in files # 1, 5 and 6.
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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 |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Drug and alcohol histories were incomplete in files reviewed. All areas specified under this regulation must be addressed completely. File # 6 was missing a D&A history and file # 7 did not address length and patterns, prior treatment or family use/abuse patterns in detail.
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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 |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Personal histories lacked sufficient detail to permit meaningful treatment plan formulation. Histories need to address all areas required by this regulation and should collect as much detail as possible. Personal histories were incomplete in files # 1, 2, 3 and 7. File # 6 did not have a personal history.
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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 |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
The discharge summary was late in one file reviewed (# 2) and was incomplete in one file reviewed (# 3). Within one week after discharge, there should be entered into the client's case record a discharge summary describing the reasons for treatment services offered, response to treatment and client's status or condition upon discharge.
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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 |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Follow up must be consistently documented in accordance with agency policy. Follow up was not documented for all types of discharges.
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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 |