INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 7, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Caron Counseling Services 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 December 30, 2009.
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Plan of Correction
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709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records on December 7, 2009, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment in one of two client records.
The findings include:
Ten client records were reviewed on December 7, 2009. Of those ten client records, only two clients were involuntarily terminated. Two client records required documentation of a written notice of termination. A written notice of termination was not documented in one of the two records that required a written notice of termination, client record #9.
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Plan of Correction
Plan of Correction: All client records where the client was involuntarily terminated from treatment will have written documentation of the notice of termination form. All Staff were trained on this procedure (12/11/09). Ongoing monitoring will be done by the Director during monthly chart reviews.
Completion Date: 12/11/09 |
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.
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Observations
Based on a review of personnel records and staff interview, the facility failed to provide documentation of at least four hours of TB/STD training in one of three personnel records.
The findings include:
Three personnel records were reviewed at the Human Resources department on December 1, 2009. Documentation of at least four hours of TB/STD training for personnel #3 was not provided and could not be located by Human Resources.
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Plan of Correction
Plan of Correction: Personnel #3 will attend the four hour TB/STD training. The Director registered the staff member for this training which is to be held on March 10, 2010. The training certificate will be given to Human Resources upon completion of the training. The Director will follow-up with HR to make sure they have received the training certificate/hours for this employee.
Completion date: 3/10/2010 |