INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 11, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Warren General Hospital 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 July 7, 2009.
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Plan of Correction
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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.
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Observations
Based on the review of personnel records, the facility failed to document that the project director and facility director completed at least 12 clock hours of training annually in one of two personnel records.
Findings:
Seven personnel records were reviewed on June 11, 2009. There were no training hours documented for the 2007-2008 training year in personnel record # 1, the personnel record representing the project director.
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Plan of Correction
The Project Director will ensure that all employees comply with the education requirements set forth in 28 Pa. Code 704.11(d). Although the Project Director did not complete the education requirements for the 2007-2008 training year, the Project Director corrected this deficiency and did complete the requisite training during the 2008-2009 training year, and will continue to obtain 12 hours of education during subsequent training years. |
157.21 (b)(3) LICENSURE Admission - detoxification.
157.21 Admission - detoxification.
(b) Admission procedures shall include documentation of the following:
(3) Physical examination.
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Observations
Based on the review of client records, the facility failed to document that the physical examination of the client was completed according to the policy of the facility in one of three client records.
Findings:
Three client records were reviewed. Three client records were required to have physical examinations completed and documented in the client record. The facility's policy states that a physical examination will be completed within 24 hours of admission. In client record # 2, the client's admission date was April 19, 2009. The physical examination was not completed until April 21, 2009.
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Plan of Correction
The Project will educate the Medical Director, Counselor, and nursing staff regarding the facility's policy that Histories and Physicals are completed within 24 hours of admission. The Counselor will monitor charts for compliance with the policy and will alert the Medical Director when a History and Physical is not present within 24 hours of admission. The Project Director, or designee, will conduct a chart audit during September 2009 to determine whether further corrective action is necessary. |