INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 1, 2007 and August 2, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Holcomb Associates, 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 and a plan of correction is due on August 30, 2007.
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Plan of Correction
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705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on the physical plant inspection on August 2, 2007, the facility failed to ensure the exhaust fan in the second floor unisex bathroom was operable.
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Plan of Correction
The exhaust fan in question was replaced on August 3, 2007. Our Safety Officer will monitor this, and all related systems, on a monthly basis, to keep systems in good working conditions. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
The facility failed to document that personnel were trained to perform assigned tasks during emergencies in four of five employee records reviewed, #2, 3, 4 and 5.
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Plan of Correction
HBHS's Orientation Process will be amended to ensure that all new employss are given basic Fire Safety training during orientation. Documentation of this process will be placed in the Employee Personnel File. |
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
The facility failed to document that alternate exit routes were used during fire drills from September 2006 through July 2007.
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Plan of Correction
The Facility Director and HBHS Safety Representative will arrange for alternate routes to be used during fire drills, and document these routes in our Fire Dtill records.
This will be incorporated in our Fire Safety program immediately. |
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 facility failed to include available resources for the 2007-2008 project goals and objectives.
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Plan of Correction
D&A Project Goals will now include both time frames and available resources needed to meet those objectives. |
709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
The facility failed to include the date that the annual work performance evaluation was completed for three of five employees reviewed, #2, 4 and 5.
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Plan of Correction
HBHS's Annual Employee Evaluations will be amended to include the date of completion and signature. |
709.28(c)(3) 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:
(3) Purpose of disclosure.
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Observations
The facility failed to document a purpose for disclosure of client information that was consistent with the release of information to the probation officer in four of five client records reviewed, #1, 3, 4 and 7.
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Plan of Correction
HBHS will provide additional training to staff around the issue of Confidentiality, to ensure that all information released to a probation officer be documented with a release that clearly states that the purpose of ther disclosure is to "Comply with legal requirements". The Program Supervisor will implement this training, and the treatment staff will institute this process immediately.
The program Clinical Supervisor will monitor this process, and, in addition, be responsible for training any new staff on this issue. |
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
The facility failed to document ac complete psychosocial evaluation in four of six client records reviewed. Psychosocial evaluations included client statements instead of the counselor's assessment of the clients's coping mechanisms, support systems, assets and strengths and negative factors that may inhibit treatment in four of six client records reviewed, #1, 2, 3, 4 and 6.
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Plan of Correction
Treatment Staff will be trained to use their assessment of client statements as part of the psychosocial evaluation, instead of just restating the client's
statements alone, in the areas of coping mechanisms, support systems, assests, strengths, and negative factors that may inhibit treatment. The Program Clinical Supervisor will be responsible for monitoring this corrective action. HBHS will begin to institute this approach immediately. |
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
The facility failed to document the treatment plan update within 60 days of the comprehensive treatment plan in one of two records reviewed, #5. The facility failed to include an assessment of the client's progress in relationship to the stated goals of the treatment plan in two of two records reviewed, #2 and 5.
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Plan of Correction
Additional Training and oversight will be provided by HBHS to ensure that treatment Plan Updates are completed in a timely fashion. This training will also stress the need to include an assessment of the client's progress in relationship to the stated goals.
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