INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 6, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Adapt Outpatient Treatment Services 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 February 3, 2011.
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Plan of Correction
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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
Based on a review of the fire drill logs and an interview with the counselors who completed the fire drills, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings include:
Fire drill logs were reviewed on January 6, 2011. The facility did not document any alternate exit used during fire drills. The stairwell to the right of the facility's suite was the only route used on the following fire drills: 3-30-10, 4-19-10, 5-6-10, 6-30-10, 7-21-10, 8-16-10, 9-14-10, 10-2-10, 11-1-10, and 12-8-10.
This documentation was confirmed through staff interviews.
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Plan of Correction
Both the Counselor and Clinical Supervisor shall immediatley prepare and be responsible for ensuring that alternate exit routes are used during fire drills
The Counselor and Clinical Supervisor shall be responsible for documenting in the facility fire drill log both fire drills and the alternating routes used during the fire drills. Effective February 2, 2011.
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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
Based on a review of client records, the facility failed to document follow-up in one of the four required records.
The findings include:
Eight client records were reviewed on January 6, 2011. Four of the eight client records were discharged clients and required documentation of follow-up attempts. Follow-up was not documented in one of the four required client records.
Client # 8 was admitted on 7-21-2010 and discharged on 11-22-2010. The follow-up attempt documentation was due on 11-29-2010. As of 1-6-11, follow-up documentation was not included in client record # 8.
This was a repeat citation from the last inspection.
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Plan of Correction
The Clinical Supervisor shall routinely monitor and ensure that the records (client files)of discharged clients shall include documentation of follow-up attempts made within 7 days of the client's discharge.
This monitoring system shall occur on a weekly basis and start the week of January 24, 2011. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records on January 6th,2011, the facility failed to ensure that staff persons received a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD and other health related topics within the first year of employment for clinical staff and within two years of employment for non-clinical staff. A review of four personnel records, #1,2,3, and 4 revealed that one staff person's record was missing the required training hours within the first or second year of employment respectively.
Record #4 was missing TB/STD requirements due to a cancelled training however, this was a repeat citation from the last inspection.
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Plan of Correction
The Facility Director shall ensure that all staff persons shall receive, within the required timeframe, the necessary number of training hours associated to HIV/AIDS and TB/STD.
A TB/STD training presented by Berks Aids Network/Co-County Wellness is scheduled to take place no later than March 2011. The facility director will ensure that the staff person whose TB/STD training was missing, due to the death of the trainer's father, shall attend this upcoming scheduled training. |