INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on December 3 and 4, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Asociacion de Puertorriquenos en Marcha Proyecto Nueva Vida 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 January 13, 2009.
|
Plan of Correction
|
704.1-704.2(a) LICENSURE Staffing Compliance Plan
CHAPTER 704. STAFFING REQUIREMENTS FOR DRUG AND ALCOHOL TREATMENT ACTIVITIES
704.1. Scope.
This chapter applies to staff persons employed by drug and alcohol treatment facilities which are licensed or approved under Chapters 157, 709 and 711 (relating to drug and alcohol services; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility) with the exception of staff persons employed in intake, evaluation and referral facilities as delineated in Chapter 709, Subchapter D (relating to standards for intake, evaluation and referral activities) and Chapter 711, Subchapter C (relating to standards for intake, evaluation and referral activities). Staff persons shall possess the qualifications set forth in this chapter and shall also participate in training as required in this chapter.
704.2. Compliance plan.
(a) The project's governing body shall approve a written compliance plan to insure that the staff persons affected by this chapter meet the appropriate educational and experiential qualifications and receive training as stipulated in this chapter.
|
Observations
Based on a review of administrative documents, the facility failed to document that the governing body approved a written compliance plan to insure that the staff meet the appropriate educational and experiential qualifications and receive training as stipulated in Chapter 704.
Findings:
The policy and procedures manual was reviewed on December 3, 2008. The facility failed to provide documentation of governing body approval of a written compliance plan to insure that the staff met the appropriate educational and experiential qualifications and received training as stipulated in Chapter 704.
|
Plan of Correction
DVP of health services will develop a policy procedure that outlines documentation of governing body approval of a written compliance plan to insure that the staff met the appropriate educational and experiential qualifications and received training as stipulated in Chapter 704.
Targeted completion 2/29/2009. |
704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
|
Observations
Based on a review of personnel records, the facility failed to document monthly meetings for the clinical supervisor for the first six months of employment in that position.
Findings:
One personnel record for clinical supervisor was reviewed on December 3, 2008. The facility did not document monthly meetings for personnel record #2. The clinical supervisor was hired on 8/18/08. The facility documented one team meeting on September 12, 2008 and one supervision meetings on October 12, 2008.
|
Plan of Correction
The facility director will conduct individual monthly supervision with CD of program in addition to the ongoing documentation made of group supervision with other managers. All these monthly meetings will be documented in personnel records in a timely manner.
Implementation to start immediately.
The Deputy Vice-President for Health Services will monitor for compliance.
|
704.11(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
|
Observations
Based on a review of five personnel records on December 3, 2008, the facility failed to document an assessment of staff training needs in four of four personnel records reviewed.
Findings:
Five personnel records were reviewed on December 3, 2008. The facility did not document any assessment of staff training needs in personnel records #1, 2, 3 and 5.
|
Plan of Correction
Deputy of Vice-President of Health Services, Clinical Director of Program and Human Resources Director will meet to review staff charts. CD of program will complete all missing training assessment forms. Deputy Vice-President of Health Services will ensure that an assessment of staff training needs for each employee will be completed annually. All new hires will have an assessment done within 30 days from hire. Targeted completion 3/2/2009. |
704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
|
Observations
Based on a review of administrative and training records, the facility failed to document an overall training plan for the 2008/2009 training year.
Findings:
The policy and procedures manual and training records were reviewed on December 3, 2008. The facility did not document an overall training plan for the 2008/2009 training year.
|
Plan of Correction
An overall training plan will be developed annually by the project director. Training plan will be posted in all health services offices by 3/2/2009. |
704.11(a)(4) LICENSURE Evaluation of Overall Plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(4) An annual evaluation of the overall training plan.
|
Observations
Based on a review of administrative and training records, the facility failed to document an evaluation of the 2007/2008 overall training plan.
Findings:
The administrative and training records were reviewed on December 3, 208. The facility did not document an evaluation of the 2007/2008 overall training plan.
|
Plan of Correction
An annual evaluation of the prior year's training plan will be completed on or about March 2, 2008, and by the project director.
|
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
|
Observations
Based on a review of personnel records, the facility failed to document a written individual training plan for two of three personnel records reviewed. As per facility policy, individual training plans are to be completed in June.
Findings:
Five personnel records were reviewed on December 3, 2008. Three personnel records required an individual training plan. The facility did not document a training plan in personnel record #2. The facility did not document an individual training plan as required by June in personnel record #3. The individual training plan for personnel record #3 was completed in October, 2008.
|
Plan of Correction
DVP of Health Services and CD of program will review all personnel charts. CD of program will renew and complete all individualized plan by 6/30/2009. An individual training plan will be completed annually and within 30 days for new hires. |
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.
|
Observations
Based on a review of personnel records, the facility failed to ensure that staff persons and volunteers received a minimum of 6 hours of HIV/Aids and at least 4 hours of TB/STD and other health related topics within the first year of employment for clinical staff and within two years of employment for non-clinical staff.
Findings:
Five personnel records were reviewed on December 3, 2008. Two were required to have HIV/Aids and TB/STD training. Employee #1 was hired as a non-clinical staff member in March, 2008 and did not have documentation of HIV/Aids and TB/STD using a Department approved curriculum. Employee #3 did not have documentation of the required number of hours of training for HIV/Aids and TB/STD. Employee #3 had a total of 6 hours of training for HIV/Aids and TB/STD training.
|
Plan of Correction
That the Deputy Vice-President of Health Services will ensure that documentation of six hours of HIV/Aids and four hours of TB/STD training will be provided within one year of hire for clinical staff and within two years of hire for all other staff.
|
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
|
Observations
Based on a review of the project director's personnel record, the facility failed to document at least 12 clock hours of training for the 2007/2008 training year.
Findings:
There were no training hours documented for the project director for the 2007/2008 training year.
|
Plan of Correction
Deputy Vice-President of Health Services will ensure that all relevant training (at least 12 hours of training per year) is documented in the credentialing file of project director. The Deputy Vice-President of Health Services with the assistance of the Human Resource Director will audit the credentialing file of the project director on quarterly basis. In addition, the Deputy Vice-President of Health Services with the assistance of the Human Resource Director will coordinate with project director the scheduling of required training hours. Targeted implementation of practice 3/2/2009. |
705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
|
Observations
Based on the physical plant inspection, the facility failed to store all trash, garbage and rubbish in noncombustible, covered containers.
Findings:
The physical plant inspection was conducted at 10:30 am on December 4, 2008. The facility failed to store all trash, garbage and rubbish in covered containers. The trash container was not completely covered as half of the lid was missing.
|
Plan of Correction
VP of economic and community development spoke with the manager of the agency's maintanance department. A call was placed to the supplier company. The trash container was replaced by Spano Co on 1/5/09. |
705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
|
Observations
Based on the physical plant inspection, the facility failed to ensure that each bathroom was ventilated by an exhaust fan or window.
Findings:
A physical plant inspection was conducted at 10:30 am on December 4, 2008. The exhaust fan in the client bathroom in the rear, right-side of the building was inoperable and there was no window in this bathroom.
|
Plan of Correction
maintanance department worker replaced the exhaust fan in bathroom on or about 12/29/2008. |
705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
|
Observations
Based on the physical plant inspection, the facility failed to ensure that all exits from the facility were unobstructed.
Findings:
The physical plant inspection was conducted at 10:30 am on December 4, 2008. The exit to the street from the basement was obstructed by a piece of wood which covered the stairs hindering access to the exit.
|
Plan of Correction
CD of program and maintanance supervisor will periodically conduct walkthru of the facility. CD will assure that all exit do not have any obtructions in their pathway. Targeted date of implementation 12/5/2008. |
705.28 (a) (1) (iii) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(iii) Maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18 inch drop with a well-secured railing.
|
Observations
Based on the physical plant inspection, the facility failed to maintain each interior stairway exceeding two steps with a well-secured handrail.
Findings:
The physical plant inspection was conducted at 10:30 am on December 4, 2008. The facility did not provide a handrail for the stairway to the front exit from the basement to the outside.
|
Plan of Correction
A list with physical plan deficiencies was given to the manager for the maintanance department on Decemeber29, 2008. Building of handrail will be completed by March 2009. |
705.28 (c) (1) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(1) Maintain a portable fire extinguisher with a minimum of an ABC rating which shall be located on each floor. If there is more than 2,000 square feet of floor space on a floor, there shall be an additional fire extinguisher for each 2,000 square feet or fraction thereof.
|
Observations
Based on the physical plant inspection, the facility failed to maintain a fire extinguisher with a minimum of an ABC rating located on each floor.
Findings:
The physical plant inspection was conducted at 10:30 am on December 4, 2008. The facility failed to maintain a fire extinguisher on the basement level of the building.
|
Plan of Correction
A list with physical plan deficiencies was given to the manager for the maintanance department on Decemeber29, 2008. Installation of fire extinguisher will be completed by January30,2009. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
|
Observations
Based on a review of personnel records, the facility failed to document that staff were instructed in the use of the fire extinguisher upon staff employment.
Findings:
Five personnel records were reviewed on December 3, 2008. Documentation of instruction to staff in the use of the fire extinguisher was required in one personnel record. The facility did not document the instruction in the use of the fire extinguisher in personnel record #2.
|
Plan of Correction
DVP and CD will create a document which will validate the training received as part of their work orientation. DVP will recruit the assistant of supervisor of maintanance department on this training. Staff will cosigned this form. Documentation will be recorded on all personnel charts by 2/28/2009. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
|
Observations
Based on a review of the fire drill record, the facility failed to document unannounced fire drills at least once a month.
Findings:
The fire drill records were reviewed on December 3, 2008. There was no documentation of a fire drill being conducted in April 2008.
|
Plan of Correction
CD of program will document in his calendar a date each month to conduct fire drill. Each fire drill date will vary on time and date. Implementation of corrective action was implemented on 12/19/2008. |
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.
|
Observations
Based on a review of personnel records, the facility failed to document that all personnel were trained to perform assigned tasks during emergencies.
Findings:
Five personnel records were reviewed on December 3, 2008. Training to perform assigned tasks during emergencies was required in four personnel records. The facility did not document the training to perform assigned tasks during emergencies in personnel record #2.
|
Plan of Correction
CD of program will assure that all staff are train to perform a task in emergencies. Training was conducted on 12/5/2008 by CD and supervisor of maintanance department. All staff was in attendance. Task completed 12/15/2008. |
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.
|
Observations
Based on a review of the fire drill records, the facility failed to document alternate exit routes were used during fire drills.
Findings:
Fire drill records were reviewed on December 3, 2008. Documentation of the exit routes used during the monthly fire drills included the use of both the front and the back exits of the building for each fire drill. There was no documentation of alternate exit routes being used for any fire drills conducted since January 2008.
|
Plan of Correction
CD will modify the fire drill form to include the exit utilize during drill. Targeted completion of task 1/30/2009. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
|
Observations
Based on a review of fire drill records, the facility failed to document that the fire drills were conducted on different days of the week, at different times of the day and on different staffing shifts.
Findings:
The fire drill records were reviewed on December 3, 2008. The facility documented fire drill times between 3 pm and 4:35 pm for each fire drill conducted between January 2008 and June 2008. The facility documented fire drill times between 12 pm and 1 pm for each fire drill conducted between July 2008 and November 2008. The facility did not document that fire drills were conducted during the morning hours or during any evening hours.
|
Plan of Correction
CD will scheduled fire drills on different week days and times on the monthly basis. Targeted implementation completed 12/19/08. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
|
Observations
Based on a review of administrative documentation, the facility failed to make available to the public an annual report.
Findings:
Administrative documentation was reviewed on December 3, 2008. An annual report for the public was required. The facility did not document an annual report.
|
Plan of Correction
President and CEO of APM will will ensure that the annual report is made available to the public each year. DVP of health services will ensure a copy of the annual report will be provided at the licensing inspection. |
709.22(e)(1) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(1) Activities and accomplishments of the preceding year.
|
Observations
Based on a review of administrative documentation, the facility failed to document an annual report to include the activities and accomplishments of the 2006-2007 fiscal year.
Findings:
Administrative documentation was reviewed on December 3, 2008. The activities and accomplishments of the 2006-2007 fiscal year were required in an annual report. The facility did not document an annual report.
|
Plan of Correction
DVP of health services will assure the annnual report includes activities and accomplisments. Targeted completion immediately. |
709.22(e)(2) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(2) A financial statement of income and expenses.
|
Observations
Based on a review of administrative documentation, the facility failed to document an annual report to include a financial statement of income and expenses of the 2006-2007 fiscal year.
Findings:
Administrative documentation was reviewed on December 3, 2008. A financial statement of income and expenses for the 2006-2007 fiscal year was required in an annual report. The facility did not document an annual report.
|
Plan of Correction
DVP will assure that annual statement includes financial statement from prior year. 1/30/09 |
709.22(e)(3) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(3) A statement disclosing the names of officers, directors and principal shareholders, where applicable.
|
Observations
Based on a review of administrative documentation, the facility failed to document an annual report to include a statement disclosing the names of officers, directors and principal shareholders.
Findings:
Administrative documentation was reviewed on December 3, 2008. A statement disclosing the names of officers, directors and principal shareholders was required in an annual report. The facility did not document an annual report.
|
Plan of Correction
DVP of health will assure that a copy of annual report is place along the program operation manual. DVP confirms with DVP of external affairs that annual report includes the listing of officers, directors and shareholders.Targeted completion 1/30/09. |
709.23(a) LICENSURE Project Director
709.23. Project director.
(a) The project director shall prepare and annually update a written manual delineating project policies and procedures.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the project director failed to prepare annually and update a written manual delineating policies and procedures.
Findings:
The facility ' s policy and procedures manual was reviewed on December 3, 2008. A sign-off by the project director indicating an annual update of the manual was required. The project director did not update the policy and procedures manual for the fiscal year of 2008-2009.
|
Plan of Correction
The project director will update the manual along with the sign off sheet on the annual basis. Implementation 1/30/2009. |
709.23(b) 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:
|
Observations
Based on a review of the facility ' s policy and procedures manual, the project director failed to assist the governing body in formulating policy and presenting it to the governing body at least annually.
Findings:
The facility ' s policy and procedures manual was reviewed on December 3, 2008. A sign-off by the project director indicating formulation and presentation of policy to the governing body was required. The project director did not sign-off on the policy and procedures manual
|
Plan of Correction
The Project Director will assist the governing body in formulating policy and will present it to them at least annually but for 2009 it will presented to the governing body at the next meeting. This will be documented by dated sign off by the project director and a member of the board. The project director will be responsible to review this annually to ensure it does not recur.
|
709.23(b)(3) 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:
(3) A performance report summarizing the progress towards meeting goals and objectives.
|
Observations
Based on a review of the facility ' s policy and procedures manual and administrative documentation, the facility failed to document a performance report summarizing the progress towards meeting project goals and objectives.
Findings:
The facility ' s policy and procedures manual and administrative documentation were reviewed on December 3, 2008. A performance report summarizing progress towards meeting project goals and objectives was required. The facility did not document a performance report.
|
Plan of Correction
DVP of health will assure that a copy of the performance report summarizing progress towards meeting project goals and objectives is place along the progam's operation manual. Targeted completion of task 1/30/2009. |
709.24(b) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(b) The project shall obtain written letters of agreement or understanding with primary referral sources.
|
Observations
Based on a review of the facility ' s administrative documentation, the facility failed to obtain letters of written agreement or understanding with primary referral sources.
Findings:
The facility ' s administrative documentation was reviewed on December 3, 2008. The facility was required to document letters of agreement with primary referral sources. The facility did not document letters of agreement.
|
Plan of Correction
DVP of health and CD of program will review all letters of agreement with primary referral sources. CD and DVo of health will secure these are documented along the operation manual. CD will review these on the quarterly basis for compliance. Any update needed will be made by CD by 2/29/209. |
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
|
Observations
Based on a review of administrative documentation, the facility failed to document a written agreement with a licensed hospital or physician for 24-hour emergency medical coverage.
Findings:
The facility ' s administrative documentation was reviewed on December 3, 2008. A written agreement with a licensed hospital or physician for 24-hour emergency medical coverage was required. The facility did not document a written agreement for 24-hour emergency medical coverage.
|
Plan of Correction
CD of program will establish via a written agreement emergency 24 hour coverage with at least 2 hospital in the neigborhood of the program. The agreement will be for 24 hour emergency medical coverage. Targeted completion of task 2/29/2009. |
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:
|
Observations
Based on a review of client records, the facility failed to document informed and voluntary consent from the client for the disclosure of information in eight of eight client records.
Findings:
Eight client records were reviewed on December 4, 2008. Informed and voluntary consent from the client for the disclosure of information was required in eight client records. The facility did not document informed and voluntary consent in client records # 1, 2, 3, 4, 5, 6, 7 and 8.
Urine drug screens completed by Atlantic Laboratory were documented in Client records. The facility did not document informed and voluntary consent for the release of client information to Atlantic Laboratory in Client Records #1, 2, 3, 4, 5, 6, 7 and 8.
Correspondence with the Department of Public Welfare was documented in client records. The facility did not document informed and voluntary consent for the release of client information to the Department of Public Welfare in client records # 1, 2 and 5.
|
Plan of Correction
An informed and voluntary consent will be obtained from the client for any release of information. The Clinical Director will establish a policy and procedure that will specifically set forth scheduled review of charts for every other week. In addition to this the Deputy Vice-President for Health Services will randomly review client charts to ensure that the consents are properly obtained and that Clinical Directors are reviewing charts in a timely fashion.
Targeted completion 3/2/2009. |
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.
|
Observations
Based on a review of client records, the facility failed to document the purpose for the disclosure of client information in six of eight client records.
Eight client records were reviewed on December 4, 2008. The purpose for releasing client information was required to be documented in eight client records. The facility did not document the purpose for disclosing information in client records #1, 2, 4, 5, 6 and 7
The purpose for disclosing client information to probation and parole was not documented in client records # 1, 2, 4, 5, 6 and 7.
The purpose for disclosing client information to a named individual was not documented in client records # 1, 2, 4 and 5.
|
Plan of Correction
CD of program will secure through chart review that all charts icluding 1, 2, 4 5, 6, and 7 include purposes of disclosure in the consent sign by patients. The CD will conduct training of staff within 14 days on the the purpose for the disclosure of client information and required documentation. Subsequently, the CD will review charts on a weekly basis for three months. A quarterly review of randomly selected charts will be done on a quarterly basis if full compliance is obtained during that three month period. Targeted completion 5/29/2009.
Project Director will monitor for compliance. |
709.31(b) LICENSURE Uniform Data Collection System
709.31. Uniform Data Collection System.
(b) A data collection and record-keeping system shall be developed that allows for the efficient retrieval of data needed to measure the project's performance in relationship to its stated goals and objectives.
|
Observations
Based on a licensing inspection, the facility failed to demonstrate a data collection and record keeping system that allows for the efficient retrieval of data as needed.
Findings:
A licensing inspection was completed on December 3-4, 2008. The facility did not retrieve request information in a timely manner throughout the duration of the inspection.
Personnel records and were requested by the licensing specialist at approximately 9:20 a.m. These records were not received until approximately 11:50 a.m.
|
Plan of Correction
DVP of health and CD of program will assure that all information requested by BDAP staff prior to visit is collected and made available upon their arrival for annual inspection. Targeted completion immediatetly. |
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:
|
Observations
Based on a review of client records, the facility failed to document the completion of an individual treatment and rehabilitation plan with a client.
Eight client records were reviewed on December 4, 2008. A treatment and rehabilitation plan was required in all eight client records. The facility failed to document the completion of a treatment plan with the client in records # 2, 3, 4 and 8.
Client record #2 treatment plan due by 11/09/08, but not completed until 11/20/08.
Client record #3 treatment plan signed by counselor 08/14/08, signed by client 09/11/08.
Client record #4 treatment plan signed by counselor 07/10/08, signed by client 07/14/08.
Client record #8 treatment plan signed by counselor 05/09/08, signed by client 05/13/08.
|
Plan of Correction
Staff will be retrained by CD on how to document the completion of an individual treatment and rehabilatation plan with a client within 14 days. The charts will be audited on a weekly basis by the CD. Subsequently, an audit of randomly selected charts will take place on a quarterly basis upon correction of the deficiency. Targeted completion 5/29/2009.
Project Director will monitor to insure compliance.
|
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
|
Observations
Based on a review of client records, the facility failed to document follow-up information in three of three client records.
Findings:
Eight client records were reviewed on December 4, 2008. Follow-up information was required in three of three client records. The facility did not document follow-up information in client records #6, 7 and 8.
|
Plan of Correction
Staff will be retrained by CD on how to document follow-up information in client records within 14 days. As part of this training the staff will be instructed on how to document clients referred elsewhere and document that follow-up will be conducted within 7 days. The charts will be audited on a weekly basis by the CD. Subsequently, an audit of randomly selected charts will take place on a quarterly basis upon correction of the deficiency. Targeted completion 5/29/2009.
Project Director will monitor to insure compliance. |