INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 19 and 20, 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 April 24, 2007.
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Plan of Correction
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704.11(f)(1) LICENSURE Counselor's Trng Req
704.11. Staff development program.
(f) Training requirements for counselors.
(1) Subject areas for training shall be selected according to the training plan for each individual.
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Observations
Client records #5 and 6 did not have the minimum number of training hours required for the 2006 training year.
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Plan of Correction
The new training system is being developed/managed by two people, Clinical Supervisor, Program Manager. They will be responsible for developing individual training plans that coincide wit individual need and state requirements. Clinical Supervisor will ensure compliance. Program Director will monitor. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Fire drill logs are missing the documentation of evacuation times for drills conducted on
1-26-07 and 2-7-07. In addition, the logs are missing documentation of exit routes used for drills conducted on 12-28-06 and 1-26-07.
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Plan of Correction
Health and Safety Captain will edit fire drill forms to conform to state requirements. This will be accomplished within 30 days. Program Director will ensure compliance. |
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
1.) Release forms do not provide for an informed consent. Specific information to be released, the purpose of the release and the obtain/release/verbal sections are not consistently completed and are not consistently correct.
2.) Client record #5 included a faxed letter to a judge with no corresponding consent to release information.
3.) The "Follow up contact" form continues to include a signature line for parents which is a violation of 71 P.S. 1690.112 and 42 CFR Part 2, Subpart B, Subsection 2.14(b).
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Plan of Correction
In-service training was held March 22, 2007 to rectify situation. Clinical Supervisor and Intake Coordinator will ensure compliance. Program Director will be responsible. |