INITIAL COMMENTS
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This report is the result of an on-site licensure renewal inspection conducted on January 11, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during the inspection and a plan of correction is due on February 13, 2007.
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Plan of Correction
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709.22(d)(1) LICENSURE Governing Body
709.22. Governing body.
(d) The duties of the governing body include, but are not limited to, the following:
(1) Selecting a project director as the person officially responsible to the governing body.
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Observations
The current identified project director does not complete the duties associated with this position or report to the governing body.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
The annual audit was not completed as required for the 2005/2006 fiscal year.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.28(c)(2) 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:
(2) Specific information disclosed.
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Observations
Specific information to be released (medication and specific drug use information) exceeded 4 Pa. Code 255.5 in two of four client records reviewed, #2 and 5. Consent to release forms were missing the specific information to be released in one client record, #3.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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
A notice of termination was missing in one of one client record reviewed, #8.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.10 (b) (3) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(3) Repair inoperable smoke detectors or fire alarms within 48 hours of the time the detector or alarm is found to be inoperative.
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Observations
On January 5, 2006, documentation showed that a fire detection device was inoperative. This inoperable device was reported 13 times over the past 12 months before it was repaired.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Fire extinguisher training was not documented in three of four personnel records reviewed, #8, 9 and 10.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Training to ensure personnel are trained to perform tasks during emergencies was not documented in three of four records reviewed, #8, 9 and 10.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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
Employee #11 did not have documentation of 4 hours of training in TB/STD. This was due June 2006.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |