INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 1 and 2, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Open Door Counseling at Mazzoni Center 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 May 1, 2008.
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Plan of Correction
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704.11(a)(3) LICENSURE Training Feedback
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:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of training records on 4/1/08, the facility failed to document feedback on completed training in three of five records reviewed, #1, 2 and 5.
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Plan of Correction
Program Director will meet with Staff within 15 days to review current policy regarding documentation of training feedback. Staff will submit feedback forms for all trainings to Program Director within 7 days of attending training. Program Director will review feedback forms, then submit to HR to become part of personnel record. Program Director and HR will ensure feedback forms are sumitted consistently on an ongoing basis. |
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.
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Observations
Based on a review of training records on 4/1/08, the facility failed to include potential resources in the individual training plan in four of five records reviewed, #1, 2, 3 and 4.
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Plan of Correction
Program Director will hold meeting with Staff within 15 days to discuss individual training plans. Staff will be instructed to identify potential resources for proposed trainings. Program Director will review and approve identified resources. On an ongoing basis, staff will include potential training resources on all future individual training plans, which will be approved by Program Director, and monitored for compliance on an ongoing basis. |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based on the physical plant inspection on 4/2/08, the facility failed to secure client records within locked storage containers. The active and closed client records were stored in unlocked file cabinets in an unlocked file room.
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Plan of Correction
While on the date of inspection, files were found to be in unlocked cabinets, staff and Program Director take client confidentiality very seriously, and will vigilantly ensure client confidentiality by locking the file room door after each use to ensure access is denied to anyone other than authorized personnel. Program Director will monitor for compliance on an ongoing basis by performing spot checks. |
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
Based on a review of client records on 4/2/08, the facility failed to obtain an informed and voluntary consent in one of five client records reviewed, #1. The consent to release to Keystone Blue Cross did not include the specific information to be disclosed.
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Plan of Correction
Program Director will hold meeting with staff within 15 days to review policy regarding completion of consent to release information forms. In all cases, specific information to be disclosed will be visibly marked on all consent forms. Staff will be responsible for completing forms to the expected standard. Program Director will review and monitor for compliance on an ongoing basis. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records on 4/2/08, the facility failed to document a complete psychosocial evaluation in five of five client records reviewed, #1, 2, 3, 4 and 5. Psychosocial evaluations did not include a clinical assessment of how assets/strengths, support systems and negative factors impact the potential for treatment.
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Plan of Correction
Program Director will amend the Psychosocial Evaluation form to allow for more thorough recording and documentation of client's assests/strengths, support systems and negative factors impact upon treatment, within one month. Staff will be trained on these changes and will begin using the new form immediately upon being trained. Program Director will monitor for compliance on an ongoing basis by signing off on completed evaluation forms. |
709.92(a)(1) 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of client records on 4/2/08, the facility failed to document treatment plan goals stated in terms of measurable criteria in two of four client records reviewed, #1 and 4.
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Plan of Correction
Program Director will meet with staff within 15 days to review policy regarding measurable goals and objectives on treatment plans. Staff will be trained on using measurable goals, and will begin immediately incorporating this into their work with clients. All treatment plans will reflect measurable goals and objectives on a consistent basis. Program Director will monitor for compliance on an ongoing basis by signing off on all plans. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records on 4/2/08, the facility failed to document timely treatment plan updates in three of three client records reviewed, #2, 3 and 5. Treatment plan updates were not completed within the required time frame identified in the facility's policy and procedure. In addition, treatment plan updates did not include an assessment of the clients's progress in relationship to previously stated goals.
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Plan of Correction
Program Director will meet with staff within 15 days to review policy on Treatment Plan completion and required elements. Staff will be trained on the appropriate due dates and how to incorporate progress on previously stated goals. Program Director will monitor for compliance on an ongoing basis by signing off on completed plans. |