INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 4, 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 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
There was no documentation that an assessment of staff training needs was completed.
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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(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
Individual training plans were incomplete for employees #1, 2 and 20 for the year 2006.
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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 did not include 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) 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 consent to release information forms provided by Lancaster County SCA violate 4 Pa. Code subsection 255.5(b) in regards to information to be released and the purpose of the release.
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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, 3, 4, 5, 6, 7, 8, 9 and 10, the psychosocial evaluations reviewed did not address all the required areas. In addition, the evaluations were more historical than evaluative with 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 |
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
In 6 out of 10 clinical charts reviewed, specifically #1, 4, 5, 6, 7 and 9, the short and long term goals of the comprehensive treatment plan were insufficiently supported by the action steps. In addition, the action steps were generalized and appeared to be more like goals statements.
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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
In 3 out of 6 clinical charts reviewed, specifically #3, 5 and 9, the treatment plan updates did not address the client's progress in relationship to the stated goals in the comprehensive treatment plan.
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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)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
The goals were generalized with inconsistent time frames for aftercare plans reviewed in clinical charts #9 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 |