INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on June 4, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Familylinks, Inc 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:
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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 fire drill records, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings include:
The fire drill logs for the period of June 2011 through May 2012 were reviewed on June 4, 2012. The drills which occurred in January, February, March and April 2012 as well as June, July, August, October, November and December 2011 all documented the main/front door as the exit route. The fire drills conducted in September 2011 and May 2012 did not have an exit route listed.
An interview with the facility director took place on June 4, 2012 at which time the aforementioned information was confirmed.
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Plan of Correction
The program manager discussed using different exits for each fire drill with the heath and safety officer of this site. The officer will ensure that during the monthly fire drills all exits are utilized at least one time each.
The officer will also ensure that the fire drill documentation is completed accurately and timely in addition to being copied to the Program Manager of AOD services. These corrections will begin with the July 2012 fire drills.
Program Manager for AOD will moniotor for compliance monthly |
709.82(c) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to assure that counseling services were provided according to the individual treatment and rehabilitation plan in two of three client records.
The findings include:
Three partial hospitalization client records were reviewed on June 4, 2012. All three client records were required to include documentation that counseling services were provided according to the individual treatment and rehabilitation plan. Client records # 1 and 2 did not include documentation that counseling services were provided according to the individualized treatment and rehabilitation plan.
Client #1 was admitted to partial hospitalization on May 8, 2012. The individualized treatment and rehabilitation plan was developed on May 17, 2012 and stated that client #1 would receive individual counseling 2 times per week and group counseling 5 times per week. Client #1 did not have individual counseling sessions twice per week as stated in the individualized treatment and rehabilitation plan. Since admission, client #1 had individual counseling sessions on May 10, 17, 24 and 31, 2012.
Client #2 was admitted to partial hospitalization on April 2, 2012. The individualized treatment and rehabilitation plan was developed on April 2, 2012 and stated that client #2 would receive individual counseling 2 times per week and group counseling 3 times per week. Client #2 did not have individual counseling sessions twice per week as stated in the individualized treatment and rehabilitation plan. Since admission, client #2 had individual counseling sessions on April 12, 16, 19, 25 and May 1, 3, 9, 16 and 25, 2012.
An interview with the facility director took place on June 4, 2012 at which time the aforementioned information was confirmed.
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Plan of Correction
The therapist was offering individual sessions one time weekly for a total of one hour and 19 hours of group over five days.
During supervision the Partial therapist was directed to schedule individual sessions with clients in the partial program two times each week for a minimum of ½ hour each session.
This has already begun and will continue from July 1, 2012 on. This will esnure that clinical services are being provided according to individual treatment plans. Program Manager will monitor this by regular chart reviews and weekly supervision.
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709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of client records, the facility failed to provide counseling to a client on a regular and scheduled basis, including individual counseling, at least twice weekly, in three of three records reviewed in the partial hospitalization activity.
The findings include:
Three partial hospitalization client records were reviewed on June 4, 2012. All three client records were required to include documentation of individual counseling at least twice weekly. Client records # 1, 2 and 3 did not include documentation of individual counseling at least twice weekly.
Client #1 was admitted to the partial hospitalization activity on May 8, 2012. Individual counseling sessions took place on 5/10/12, 5/17/12, 5/24/12 and 5/31/12.
Client #2 was admitted to the partial hospitalization activity on April 3, 2012. Individual counseling sessions took place on 4/12/12, 4/16/12, 4/19/12, 4/25/12, 5/1/12, 5/3/12, 5/9/12, 5/16/12 and 5/30/12.
Client #3 was admitted to the partial hospitalization activity on April 30, 2012. Individual counseling sessions took place on 5/7/12 and 5/23/12.
An interview with the facility director took place on June 4, 2012 at which time the aforementioned information was confirmed.
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Plan of Correction
The therapist was offering individual sessions one time weekly for a total of one hour and 19 hours of group over five days.
During supervision the Partial therapist was directed to schedule individual sessions with clients in the partial program two different times each week for a minimum of ½ hour each session.
This has already begun and will continue from July 1,2012 on.
This will ensure that counseling services are provided according to the individual treatment and rehabilitation plan by providing counseling to clients on a regular and scheduled basis
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