INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 8, 2005 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 30, 2006.
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Plan of Correction
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704.11(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
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Observations
No documentation was available of the assessment of staff training needs.
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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(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
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Observations
The individual training plan for the 2006 calendar year was missing for employee #1.
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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
There was documentation demonstrating that alternate exit routes were used during fire drills.
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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
The financial statement only included income and not expenses for the 2004-2005 fiscal year.
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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)(1) 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:
(1) Project goals and objectives which include time frames and available resources.
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Observations
The time frames for the project's goals and objectives were identified as "ongoing", "quarterly" or "monthly" rather than specific dates. In addition, the goals and objectives did not consistently identify the available resources.
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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
In 1 out of 4 clinical charts reviewed, specifically #1, the consent to release information form for the insurance company exceeded what is allowable by 4 Pa. Code subsection 255.5(b) for specific information released.
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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
In clinical charts #1, 2 and 3, the psychosocial evaluation did not address all the required areas. In addition, the evaluation was more historical with very little clinical insight.
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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 |