INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 14 through 16, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Treatment Trends Inc. Keenan House 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 12, 2008.
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Plan of Correction
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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 January 14 through 16, 2008 review of training records, the facility failed to document HIV/AIDS and TB/STD training in two of ten records reviewed, #7 and 8. Employee # 7 was missing documentation of both HIV/AIDS and TB/STD training. Employee # 8 was missing HIV/AIDS training.
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Plan of Correction
The agency's expectations are to fulfill the 704.11(c) standards as written. Lack of available training within a 4 hour radius hampered our efforts to comply with this standard.
Hard to locate trainings are being offered in the spring of 2008 through Treatment Trends Institute and are listed in the spring issue of the Treatment Trends Institute brochure. All staff requiring a minimum of 6 hours of HIV/AIDS training, 4 hours of TB/STD training or Ethics training are required to attend. We expect to be in full compliance by April 2, 2008. The Program Director in coordination with the Training Coordinator will review all personal files to ensure all staff members are receiving the the training necessary, that it is accurately documented in compliance with 704.11(c)and ensure the maintenance of a well trained staff. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a January 14 through 16, 2008 review of client records and facility policy, the facility failed to document treatment plan updates within the time frame identified by the facility in three of eleven records reviewed, #6, 8 and 10.
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Plan of Correction
It is the expectation that all staff members will complete their paperwork in a timely fashion. In support of this effort, the Clinical Supervisor keeps track of all paperwork deadlines including the completion of Treatment Plan Updates which are to be updated at least every 30 days.
Upon discussion, it became clear that staff were unsure how to work around holidays and weekends when a treatment plan was due and believed that they were not allowed to work with a client on a plan and have it signed before the due date. This was clarified by informing them that it is acceptable to sign a Treatment Plan Update eary in this circumstance.
Staff are expected to comply with standard 709(b) by March 17,2008. The Clinical Supervisor will continue to track due dates of all paperwork and hold accountable any staff that are delinquent. The Clinical Director will spot check Treatment Plan Updates on a quarterly basis per counselor assigned caseload. |