INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 17, 2007 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 February 20, 2007.
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Plan of Correction
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705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
The fire extinguishers have not been inspected since October 2005.
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Plan of Correction
Fire extinguishers were serviced on 1/30/07 by the Philadelphia & PA Fire Extinguisher Co, Inc. 5111 Chestnut St, Phila, PA 19139, (215) 472-1000, license #91-270 |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
The fire alarm/smoke detector has not been set off in the past 12 months.
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Plan of Correction
The Project shall set the smoke detector off when conducting each monthly fire drill. The Project Director and/or the immediate supervisor on duty at the time of the fire drill is responsible for setting off the smoke detector and recording the outcome in the fire drill log. If the smoke detector is found to be deficient the Project Director shall replace the smoke detector and test for accuracy within 24 hours of the fire drill. A notation shall be made in the fire drill log indicating the exact date of the replaced smoke detector and the Project Directors signature in the log shall serve as certification that a working smoke detector is located in the facility. |
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 program has not had clients sign consents to release information. Information has been released to CBH for funding purposes in three of three client records reviewed, #1, 2 and 3.
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Plan of Correction
The Project Director will implement a written policy that shall be included in section 709.28(c) of the agency manual that shall state that voluntary client consent muct be obtained for the disclosure of any and all information to outside sources including but not limited to CBH, insurance companies and other parties requesting information on clients enrolled in our program. A separate disclosure form specific to each entity and/or purpose shall be obtained for each entity/party. A copy of each voluntary client consent for disclosure shall be retained in the client's record. The Counselor and/or Project Director shall inform the client of this policy at orientation of written consent specific for each disclosure according to the purpose of the consent in relation to state and Federal regulations. The project shall not obtain and/or require the use of a general consent to disclose information. It shall be documented in the client record by the Counselor that the client has been informed of agency policy regarding disclosure and such entry shall certify that the client has been informed that all disclosures are provided through voluntary client consent. The client shall be informed of this policy during his/her first visit as a client of the program. The Project Director will audit program files on a monthly basis to monitor compliance with this policy. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
The preliminary treatment plans did not include drug and alcohol issues in three of three client records reviewed, #1, 2 and 3.
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Plan of Correction
The Project Director shall convene a staff in service on 3/19/07 on treatment planning to provide instruction in preparing preliminary and comprehensive treatment plans that are sufficiently inclusive of drug and alcohol issues. The Project Director shall conduct monthly chart reviews of client records to monitor and evaluate staff progress in this area and to assess the need for further staff development. Through monitoring of program charts immediate action will be taken if deficiencies are found that will include but not limited to: a) The Counselor will be required to make immediate adjustments in collaboration with the client to the service plan during the next scheduled visit. b) The Project Director will review the revised plan and provide the Counselor with feedback within 5 working days if warranted and the Counselor shall be given a reasonable period of time to work with the client to make any additional adjustments. c) Any Counselor that is required to make more than four (4) adjustments to service plans for four or more clients in his/her caseload in any calendar year will be required to attend a Clinical Training course in treatment planning with an outside agency, university or other educational institution and recieve a passing grade or certificate of completion that shall be maintained in his/her personnel record. The Project Director shall schedule semi-annual staff in service trainings on treatment planning to reinforce staff competency and ability to address this issue. |
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
Goals were not congruent with intervention/action steps identified in one of one client records reviewed, #2,
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Plan of Correction
The plan of action to correct this dificiency shall include staff in-service on service planning to include developing goals, objectives and activities. A simple tool will be employed to assist staff in developing goal components that can be aligned and accomplished with outcome objectives The Project Director shall convene a one hour session with Counselors on this topic on 3/8/07. The Project Director will also audit client records on a monthly basis to assess improvement in this area and/or the need for further training. |