INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 27, 2006 and November 28, 2006 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 January 5, 2006.
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Plan of Correction
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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
The project failed to define potential training resources on individual training plans reviewed during the survey.
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Plan of Correction
An individualized training form has been designed by the Executive Director. Beginning 6/30/07-6/30/08 annual training year individualized training plans will be completed by the Executive Director, Linda Franiewski, for each employee |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
The project failed to provide or document CPR/First Aid training for a sufficient number of staff so that at least one person trained in these skills is onsite during the hours of operation.
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Plan of Correction
The RN has registered the following employees for trainings: Susan McGonigle received Adult CPR/AED and standard First Aid on 1/9/07 and 1/10/07 at the Butler County Red Cross. Charles Jusets received Adult CPR/AED (already has current first aid) on 1/09/07 and Lisa Hohn is registered for Adult CPR/AED and standard First Aid on February 6 & 7, 2007 and Jeff Pollock is registered for Adult CPR/AED (already has current first aid)on February 6, 2007. The Executive Director and the RN will be the employees responsible for ensuring that sufficient number of staff is trained and onsite during hours of operation at all times going forward. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
The project failed to develop confidentiality procedures that comply with 4 Pa. Code subsection 255.5. The project defined procedures in regard to a "Duty to Warn" and also utilized a "Qualified Service Organization Agreement" inappropriately for that purpose.
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Plan of Correction
Immediately following the 11/27/06 - 11/30/06 licensing visit the Exectuve Director has re-written and re-defined the Gaiser Center's procedure for handling certain life-threatening situations that involve a clear and imminent danger that a client may inflict serious bodily harm on another person or pesons. The new policy recognizes these situations as "Medical emergencies" and requires that staff take all necessary actions to protect the life of the
Also,immediately following the 11/27/06 - 11/30/06 licensing visit , the executive Director destroyed and revoked the inappropriately used Qualified Service Organization Agreements. |
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
The project failed to complete a treatment and rehabilitation plan every sixty days in client record #0622.
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Plan of Correction
During weekly clinical staffing on 12/6/06 with the Clinical Director and the Executive clinical staff we reminded that each client in the Intensive Outpatient Level of Care must have a new treatment and rehabilitation plan every 60 days. All care will be taken that this error will not be repeated. |