INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 14, 2007 to May 18, 2007 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 June 12, 2007.
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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
The facility failed to provide training plans for support staff hired within the current fiscal year. This included one treatment aide and three monitors. Licensing Alert 03-05 indicates that the initial training plan for a newly hired employee be completed within 30 days from the date of hire.
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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) 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:
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Observations
The facility failed to comply with state and federal confidentiality regulations as they relate to the urine collection and testing. All clients consent to urine screening as part of the facility's program rules and sign off to such consent on the consent to treatment form. All treatment plans include a statement to the affect that the client will participate in urine screening. Confidentiality is compromised as the facility utilizes it's sister corporation Renewal, Inc. to collect the urine, and the consents for Renewal, Inc. do not include urine screening [28 Pa. Code subsection 709.28 (c)(2); 42 CFR Part 2, Subpart C, Subsection 2.31(a)(5)] and there is no quality Service Organization Agreement in place. The laboratory sends the results to both Renewal Treatment, Inc. and probation/parole [4 Pa. Code subsection 255.5(b)] Renewal Treatment, Inc. initiates and bills for all urine screens. Screen results were found in client records #3 and #5.
The facility failed to comply with 4 Pa. Code subsection 255.5(b) as probation/parole have participated, with Renewal staff, on room searches of their parolees. The facility is given notice of these searches, but the residents are not. 4 Pa. Code subsection 255.5(b) restricts the type of information that can be released to probation, room searches are not permitted by this statute. Also, even if there were no restrictions, 42 CFR Part 2 and 28 Pa Code 709.28(c) requires that the client give informed and voluntary consent. Therefore, the client is not informed as he/she is not aware of these inspections and what may result from them.
Also, the facility failed to obtain a consent for the Department of Public Welfare in client record # 4 and a consent for Allegheny County Assistance Office for client record # 5.
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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. |
709.54(c) LICENSURE Follow-up policy
709.54. Project management services.
(c) The project shall develop a written client follow-up policy.
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Observations
The facility failed to include a procedure for one week referral follow-up in its follow up policy. When a client has been discharged and referred to an outside resource, the project should, with the written consent of the client and within one week from the day the referral is to be completed, attempt to determine from the resource the disposition of the referral. Once the attempt has been made and documented, a project may consider its obligation to the individual fulfilled.
The facility also failed to follow its current follow-up policy of one month as client record numbers 4 and 5 indicate that follow up is competed within one week 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. |