INITIAL COMMENTS
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This report is a result of a supervisory review of the written report of the findings of an on-site licensing inspection that was conducted on January 10 - 11, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the supervisory review of findings from the on-site inspection, Family Service Association of Bucks County 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 supervisory review and a plan of correction is due on May 19, 2011.
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Plan of Correction
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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of the hours of operation Monday - Thursday 8:30 AM - 9:00 PM and Friday 8:30 AM - 5:00 PM, and the scheduled work days of the staff that were currently certified in Cardio Pulmonary Resuscitation (CPR) certification and First Aid (FA) cards, the facility failed to ensure that CPR certification and first aid training was provided to a sufficient number of staff persons, so that at least one person trained in these skills was onsite during the project's hours of operation.
Findings:
On April 15, 2011 copies of staff CPR and First Aid cards and the staff work schedule as provided by the facility was reviewed.
Based on the work schedule and the CPR and First Aid cards provided by the facility, the facility failed to provide CPR and First Aid coverage from 5:30 PM - 9:00 PM on Tuesday.
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Plan of Correction
The Director and Clinical Services will contact the America Red Cross by May 13, 2011 to arrange an on-site CPR and First Aid Training to take place no later than June 30, 2011. The Director of Clinical Services will mandate that a sufficient number of staff members participate in the training to ensure that a minimum of two (2) staff members per shift and trained in both CPR and First Aid. |
709.92(a) 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:
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Observations
Based on a review of client records, the facility failed to develop an individualized comprehensive treatment plan with the client in six of eight records reviewed.
The findings include:
On April 15, 2011 documentation of eight client records were reviewed for individualized comprehensive treatment plans.
Client #2 was admitted to treatment on 5/25/10. The facility documented that he comprehensive treatment plan was completed on 5/25/10; however the the psychosocial histories and the biopsychosocial evaluation were not completed until 6/10/10.
Client #3 was admitted to treatment on 6/3/10. The facility documented that he comprehensive treatment plan was completed on 6/8/10; however the the psychosocial histories and the biopsychosocial evaluation were not completed until 6/25/10.
Client #4 was admitted to treatment on 9/23/10. The facility documented that he comprehensive treatment plan was completed on 9/23/10; however the the psychosocial histories and the biopsychosocial evaluation were not completed until 9/30/10.
Client #6 was admitted to treatment on 5/19/10. The facility documented that he comprehensive treatment plan was completed on 5/19/10; however the the psychosocial histories and the biopsychosocial evaluation were not completed until 6/1/10.
Client #7 was admitted to treatment on 8/16/10. The facility documented that he comprehensive treatment plan was completed on 8/23/10; however the the psychosocial histories and the biopsychosocial evaluation were not completed until 8/26/10.
Client #8 was admitted to treatment on 4/13/10. The facility documented that he comprehensive treatment plan was completed on 4/13/10; however the the psychosocial histories and the biopsychosocial evaluation were not completed until 5/3/10.
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Plan of Correction
On April 28, 2011 the Director of Clinical Services met with the Clinical Supervisors to review regulatory standard 709.92(a), Treatment and Rehabilitation Services and to develop a Plan of Correction in order to ensure going, consistent compliance with this standard. The agreed upon Plan of Correction specified that Clinical Supervisors would meet with each of their assigned clinical staff members no later than May 13, 2011 to review the standard and to specifically emphasize the importance of completing the Biopsychosocial History and Assessment prior to completing an individualized, comprehensive Treatment Plan. Clinical Supervisors will regularly monitor client records to ensure ongoing compliance. The Director of Clinical Services will reinforce consistent adherence to this standard at a Behavioral Health Program Staff meeting scheduled for June 15, 2011. |