INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 20 through June 22, 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 July 19, 2006.
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Plan of Correction
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704.11(a)(1) LICENSURE Training Needs assessments
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:
(1) An assessment of staff training needs.
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Observations
An assessment of training needs was not completed.
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Plan of Correction
This year in December of 2006 when I (T.Claessens)
meet with staff to assess staff training needs for the upcoming year, I will be sure to document "IN WRITING"
what we come up with and then by the end of January develop individual plans
for each staff and place copies in their files. I (program director) will do this annually.
On Monday 8-14-06 the program director will meet with staff and do an assessment of staff training needs for the remainder of this year and place a copy in each of their files |
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
Individual training plans were missing in all employee records reviewed.
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Plan of Correction
In December of 2006 Terry Claessens will meet with staff to assess staff training needs for the upcoming year. He will be sure to DOCUMENT IN WRITING
the assesment and then by the end of January 2007 develop individual training plans for each staff. These will be docmented in WRITING and placed in their individual files. The program director will repeat this procedure every year.
On 8-14-06 after doing an assessment with the staff the program director and staff will develop individual training plans for the remainder of 2006. These plans will be placed in their individual files. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Two of three counselors, #2 and 4, did not receive the required number of training hours.
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Plan of Correction
Each staff will work with the program director in putting in writing what their remaining plan of training is for 2006. This will be completed by the 7th of August and include what courses have been taken thus far in 2006 and how many total hours this gives them.
Thereafter, each staff member will turn in a monthly report at the first weekly staff meeting of each month to the program director. This report will include what trainings have been taken for the previous month and what trainings remain for them to fulfil their plan for that year.
Then in Dec. of 2006 at the first weekly staff meeting the program director will meet with the staff to assess their training needs for 2007. By the end of Jan. the program director will develop individual training plans for each staff for 2007 and hand them out to each staff at the first weekly staff meeting in FEb.
Thereafter each staff will turn in a written report at each weekly staff meeting the first of each month containing what they have taken and what remains to be taken for 2007. |
705.5 (a) (1) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(a) In each residential facility bedroom, each resident shall have the following:
(1) A bed with solid foundation and fire retardant mattress in good repair.
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Observations
Mattresses were missing for four beds.
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Plan of Correction
The program director has ordered (as of July 14, 2006) 4 fire retardant twin mattresses and they should be delivered and in the student rooms by August 15th. |
705.7 (b) (3) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(3) Clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
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Observations
Eating utensils were not stored in an enclosed area.
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Plan of Correction
Kitchen Supervisor will purchase a cover for the utensil holder on 7/20/06. The Kitchen Supervisor will instruct the Meal Monitor to insure that the covering is placed over the utensil dispenser during the clean-up time after each meal. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
There was no documentation of fire drills being conducted during 2005.
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Plan of Correction
I (T Claessens) will save the fire drill log for this (2006) year so that it can be seen at the next on site inspection along with the 2007 log. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Only one fire drill was documented during sleeping hours over the past thirteen months.
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Plan of Correction
This was a problem because of not saving the 2005 log. I will save the 2006 log and the 2007 log will be available at the next on site inspection. This will document fire drills being done in accordance with PA licensing rules and our own policy regarding fire drills. |
709.28 (c)(1) 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 shall include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Several signed blank consents to release information forms were in client record #4.
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Plan of Correction
The program director will review each counsellors student file at the third weekly staff meeting each month to look for signed blank consents to release information. If any are found , they will be removed immediately. However, I don't forsee this as being a problem again with the
guilty counsellor who did this. This will begin on August 21, 2006. |
709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
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Observations
Documentation that clients were informed of their rights was missing in six of six records reviewed.
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Plan of Correction
Terry Claessens contacted Joe Sacco at Rehrersburg TCTC and asked him to mail a copy of their clients rights form that they have posted. We will post it in the day room where it is visible to all our students. |
709.32(c)(1) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication.
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Observations
The facility's policy states that medications are to be self administered by clients. The dorm supervisor is currently administering medications to clients. Under Pennsylvania law, the only persons legally permitted to administer medication are physicians, physician's assistants, registered nurses and LPN's.
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Plan of Correction
A staff training was done on 7/10/06 in which Terry Claessens covered medication control (which includes how medications are to be self administered by the student and what that means). Self administration of meds by our students has always been our procedure but somehow our dorm supervisor got off track. I believe this training will correct the problem.The program director will do spot checks twice monthly to insure that meds are being self administered by student and logged properly. |
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 not completed in one of one record reviewed, #4.
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Plan of Correction
The program director will review student files with the counsellors at every third weekly staff meeting each
month. A check list will be used which will include termination notice. The program director will look to see if a termination notice is in place and to see if a copy was made available to the client when a student was terminated from the program. This will start being reviewed at the Aug. 21st 2006 weekly staff meeting. This will be an ongoing procedure each month. In addition the program director will do a training on procedures to be followed in terminating a student with all of the counsellors. This will be done on August 21, 2006. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Treatment plan updates did not include a review of progress on the prior stated goals in three of five client records reviewed, #2, 3 and 4.
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Plan of Correction
The program director will review the treatment plan updates in each of the counsellors student files at every third weekly staff meeting each month. The program director will review the goals and the progress being made on each goal to assure that
proper procedure is being followed and documented. This will begin at the third weekly staff meeting in September.The program director will do a staff training on trreatment plan updates (aug 28, 2006) to insure that updates are done correctly. |
709.53(a)(8) LICENSURE Case Consultation Notes
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:
(8) Case consultation notes.
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Observations
Case consultations were missing in two of three records, #2 and 3.
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Plan of Correction
The program director will use every third weekly staff meeting each month to review student files with the counsellors, The program director will look to see if there are case consultations in each student file within 90 days of his entrance into the program. This will start at the August 21st 2006 weekly staff meeting.The program director will do an inservice staff training on case consultations on 9-11-06 and then will follow up monthly to insure that case consults are being done properly. |
709.53(a)(9) LICENSURE Aftercare plans
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:
(9) Aftercare plan, if applicable.
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Observations
An aftercare plan was not completed in one of one record, #5.
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Plan of Correction
The program director will meet with the counsellors every third Monday of each month and review student files. The check list used to see that files are being properly kept and documented Will include aftercare plans. The program director will look for after care plans in files where they should be in place. If missing, the program director will have that counsellor complete one and put it in the student file by the next weekly staff meeting on the following Monday. |
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
Discharge summaries were incomplete in three of three client records reviewed, #4, 5 and 6. Specifically, services offered, response to treatment goals and the client's status upon discharge.
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Plan of Correction
The program director will meet with the counsellors at the weekly staff meeing on the third Monday of each month and review student files with them. Each file will be reviewed for discharge summaries and to see if the discharge summaries include services offered, response to treatment goals, and the clients status upon discharge and for all of the other necessary information included in a discharge summary. This review will begin on the 21st of Aug 2006. The program director will do an in service training on discharge summaries on 9-18-06 to insure that discharge summaries are being done properly. Then the project director will do monthly followups on the third monday of each month. |