INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 29 & 30, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on March 5, 2007.
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Plan of Correction
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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
Personnel record #3 did not have a training certificate for the HIV/AIDS training. Personnel record #8 did not have training certificates for HIV/AIDS or TB/STD trainings.
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Plan of Correction
Personnel identified did not receive the required training due to schedule conflicts and/or illness when certified sessions were scheduled. The individuals identified shall complete the mandated training sessions, based on current regional availability, by June 30, 2007.Mandated training will be scheduled for deficient employees within the next sixty (60) days by the Project Director. |
704.12(a)(3)(i) LICENSURE NonHosp Rehab
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(3) Inpatient nonhospital treatment and rehabilitation (residential treatment and rehabilitation).
(i) Projects serving adult clients shall have one FTE counselor for every eight clients.
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Observations
The client to counselor ratio is at 9:1.
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Plan of Correction
Due to the unexpected departure of a counselor, the Client to Counselor ratio rose temporarily.A waiver request permitting a 10:1 ratio has been filed. A replacement counselor has been retained as of 2/26/07.Additional counselor assistant was recruited and retained by the Project Director. |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
An exit from the basement level was blocked by a locked lattice enclosure just outside of the doorway. Therefore, you are unable to exit the building.
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Plan of Correction
A wind-resistant restraint temporarily was placed on the garden entry gate as a seasonal weather precaution.Restraint has been removed to permit unrestricted exit as of 2/7/2007. The Project Director oversaw the removal of the restraint. |
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:
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Observations
Client records #4 and 5 included releases of information which are not informed consents. Sections of the forms are not correctly completed including agency name; lists of specific information to be released that exceeded the limitations imposed at 4 Pa. Code subsection 255.5; and blank purposes. Client record #4 included a letter sent without a corresponding release of information.
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Plan of Correction
Information collection requirements were erroneously interpreted or inadvertently overlooked. The form in question has been replaced with an appropriate INFORMED CONSENT form as of 2/9/'07. Chart deficiencies have been remediated and procedures instituted to prevent recurrence. Staff training has been conducted to ensure continued compliance. Such compliance will be overseen and enforced by the Project Director. |
709.32(c)(3) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(3) Inspection of storage areas.
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Observations
Quarterly inspections of the drug storage area are not being documented.
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Plan of Correction
Drug shortage-cart inspections that were performed were not routinely recorded on a quarterly basis. A quarterly documentation procedure was instituted as of 2/15/07. Staff training has been conducted to ensure continued compliance. Such compliance will be overseen and enforced by the Project Director. |
709.53(a)(10) LICENSURE Discharge Summary
709.53. 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:
(10) Discharge summary.
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Observations
Client records #1 & 4 did not include dated signatures to indicate when they were completed. Client records #1 & 5 did not include reasons for treatment.
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Plan of Correction
Signature and information collection requirements were inadvertently overlooked.Chart deficiencies have been remediated and procedures instituted to prevent recurrence as of 2/27/2007. Staff training has been conducted to ensure continued compliance. Such compliance will be overseen and enforced by the Project Director. |