INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 6, 2006 through July 7, 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 August 16, 2006.
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Plan of Correction
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704.3 (b) LICENSURE Recruitment and Hiring
704.3. General requirements for projects.
(b) The project shall develop a policy that addresses the recruitment and hiring of staff persons who are appropriate to the population to be served. Every effort shall be made to hire staff persons representative of that population.
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Observations
The policy was missing. This is a repeat deficiency from the June 16, 2004 inspection.
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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. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
A portable space heater was in the basement entry way.
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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 (a) (1) (ii) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(ii) Maintain a minimum of two exits on every floor, including the basement, that are separated by a minimum distance of 15 feet.
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Observations
The second means of egress from the basement was locked at the time of the inspection. The surveyors were informed that only supervisors have keys to this lock. This is a repeat deficiency from the June 16, 2004 inspection.
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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 (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
Employee numbers 2, 4, and 6 did not receive this training within the required time frame.
This is a repeat deficiency from June 16, 2004.
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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) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Employee numbers 2, 4, and 6 did not receive this training within the required time frame.
This is a repeat deficiency from the June 16, 2004 inspection.
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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) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Alternate exit routes were not documented in the fire drill log.
This is a repeat deficiency from the June 16, 2004 inspection.
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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
Documentation that the fire alarm or smoke detector was set off during the fire drill was not provided.
This is a repeat deficiency from the June 16, 2004 inspection.
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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. |
709.22(a) LICENSURE Governing Body
709.22. Governing body.
(a) A project shall have a governing body and legal responsibility for the project rests in the governing body.
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Observations
The project's governing documents were not available for review at the time of the inspection.
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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. |
709.22(e)(2) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(2) A financial statement of income and expenses.
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Observations
A financial statement of income and expenses was not included in the annual report.
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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. |
709.22(e)(3) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(3) A statement disclosing the names of officers, directors and principal shareholders, where applicable.
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Observations
A statement disclosing the names of officers, directors and principal stakeholders was not included in the annual report.
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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. |
709.23(b)(3) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(3) A performance report summarizing the progress towards meeting goals and objectives.
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Observations
A performance report summarizing progress toward meeting goals and objectives was not completed for the prior year. This is a repeat deficiency from the June 16, 2004 and September 14, 2004 inspections.
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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. |
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
The letters of agreement with three hospitals did not include "24-hour emergency psychiatric and medical coverage" language. This is a repeat deficiency from the June 16, 2004 and September 14, 2004 inspections.
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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(b)(2) LICENSURE Personnel Management
709.26. Personnel management.
(b) The governing body shall adopt a written policy to implement and coordinate personnel management which includes, but is not limited to:
(2) The dissemination of employment information to project staff.
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Observations
This policy was missing.
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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(e) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
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Observations
Documentation that demonstrates employees were informed of their rights was missing. This is a repeat deficiency from the October 3, 2001 and January 14, 2002 inspections.
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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
Specific information released to an employer exceeded that allowed under 4 Pa. Code 255.5 (a)(6) in client record #5. Urine test results were released to public housing staff which exceeds that allowed under 4 Pa. Code 255.5 in client record #2 .
Specific information exceeding that allowed is a repeat deficiency from the October 3, 2001, April 4, 2003 and September 14, 2004 inspections.
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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
The drug and alcohol history did not include a completion date in client record # 2. The history was completed three days later than the program's thirty-day timeframe in client record #5. The drug and alcohol history was missing in client record #1.
This is a repeat deficiency from the October 3, 2001, January 15, 2002, July 2, 2002 and September 14, 2004 inspections.
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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
The personal history did not include a completion date in client record #2. The history was completed three days later than the program's thirty-day timeframe in client record #5. The personal history was missing in client record #1.
This is a repeat deficiency from the October 3, 2001, January 15, 2002, July 2, 2002 and September 14, 2004 inspections.
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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)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
The psychosocial evaluation did not include a completion date in client record #2. The evaluation was completed three days later than the program's thirty-day timeframe in client record #5. In addition, psychosocial evaluations were missing client problems and needs, coping mechanisms and negative factors that may inhibit treatment in three records, # 1, 2 and 5. Client's assets and strengths were missing in five records, # 1, 2, 3, 6 and 7.
This is a repeat deficiency from the October 3, 2001, January 15, 2002, July 2, 2002, June 16, 2004 and September 14, 2004 inspections.
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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)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
The preliminary treatment plan did not identify initial treatment goals based on information from the initial interview in eight of eight client records reviewed, #1, 2, 3, 4, 5, 6, 7 and 10.
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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. |
709.92(a)(1) LICENSURE Treatment and rehabilitation services
709.92. 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
The short and long term goals were not individualized and did not include specific action steps in order to achieve each goal in six of eight client records reviewed, #1, 2, 3, 4, 5 and 7.
This is a repeat deficiency from the October 3, 2001, January 15, 2002, July 2, 2002, June 16, 2004 and September 14, 2004 inspections.
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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. |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. 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
No support service types were proposed in four of eight client records reviewed, #1, 2, 5, and 10.
This is a repeat deficiency from the July 2, 2002 inspection.
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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. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Two treatment plan updates were missing in client record #1. Treatment plan updates did not include a review progress made by the client on the prior treatment plan's goals in client records #2, 3 and 10 .
This was a repeat of deficiencies from October 3, 2001, January 15, 2002, July 2, 2002, June 16, 2004 and September 14, 2004.
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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)(8) 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:
(8) Case consultation notes.
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Observations
Case consultations were missing in four of six client records, #1, 2, 3, and 10.
This is a repeat deficiency from the October 3, 2001, June 16, 2004 and September 14, 2004 inspections.
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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. |