INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 19 through 20, 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 August 16, 2006.
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Plan of Correction
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704.11(a)(2) LICENSURE Overall Training plan
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:
(2) An overall plan for addressing these needs.
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Observations
An overall training plan was not completed for the current training year. This plan is based on the assessment of staff training needs which should address training subjects, trainers and proposed dates of training.
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Plan of Correction
704.11(a)(2)The Director of OP Services is responsible for developing the agency staff development program. The training for current training year was completed on 7/31/06 and can be found in the training binder. Each year the Director of OP will complete this plan in March of each calender year. |
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
Employee #3 received 4 of the 25 required training hours for the last training year.
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Plan of Correction
704.11(f)(2) The Director of OP Services
is responsible for developing and review
training needs of each employee. Plans are developed in March of each calender year to insure each employee receives
requered number of training hours. The Director will review training files monthly. |
705.28 (a) (1) (iii) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(iii) Maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18 inch drop with a well-secured railing.
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Observations
The top five to six steps of the interior stairway leading from the first to the second floor did not have a handrail.
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Plan of Correction
705.28 (a)(1)(iii) The hand rail was installed on 8/10/06. |
705.28 (a) (1) (iv) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(iv) Clearly indicate exits by the use of signs.
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Observations
The exit sign, from the exit leading to the outside of the building in the basement, was missing.
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Plan of Correction
705.28(a)(1)(iv) The project Director
met with the Executive Director of
Colonial House Inc. and gave him verbal notification of the non-compliance exit sing.
The Exec.Dir. contact our electrician and placed an order to install the exit sing.
The exit sign was ordered on 8/7/06.
Instalation will take place in August
21, 2006. |
709.26(a)(8) LICENSURE Personnel Management
709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures which include, but are not limited to:
(8) Disciplinary actions.
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Observations
The policy and procedure did not include progressive steps of discipline.
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Plan of Correction
709.(a)(8) The implementation of a policy on progressive steps of disciplinary action was completed on
8/14/06. A copy was given to each staff
and a copy was filed in the Outpatient
Manual. |
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
The specific information to be released (consultations, consent forms and referral contacts) on consent forms to York County exceeds that allowed by 4 Pa. Code 255.5.
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Plan of Correction
709.28(c)(2) The Diirector of OP Services met with staff to discuss the proper way to fill out the consent forms. The information must be specific
to be disclose. The Dir. of OP Services
met with staff in supervision on 8/14/06
to discuss the areas that were not met
and to insure that each emplyee comply with this requerement.
The Dir. of OP Servises has established
that each employee review their client charts during supervision on a weekly basis. |
709.31(b) LICENSURE Uniform Data Collection System
709.31. Uniform Data Collection System.
(b) A data collection and record-keeping system shall be developed that allows for the efficient retrieval of data needed to measure the project's performance in relationship to its stated goals and objectives.
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Observations
An efficient record keeping system has not been developed. The project needs to demonstrate the utilization of data in relationship to program planning and evaluation.
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Plan of Correction
709.31(b) A data colletion was implemented for the retrieval of client
day of Intake, Admission to tx. date,
the review date for contonual of tx. and discharge. |
709.92(a) 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:
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Observations
Treatment plans were not individualized or based on the individual needs identified in the psychosocial evaluation.
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Plan of Correction
709.92(a) The Dir. of OP Services met with the clinical team to discuss treatment plans. The Dir. of OP Services stated that each Tx. plan needs to be individualized and based on the information provided on the spychosocial evaluation. It is the responsibility of the Dir. of OP Services to oversee that the counselors
maintain compliance in this matter. The clinical team will bring new treatment plans to weekly supervision meetings for review. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
The type of treatment services was missing in one client record, #3. The frequency of treatment services was missing in four client records, #1, 5, 6 and 9.
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Plan of Correction
709.92(a)(2)The Dir. of OP Services held a staff meeting on 7/25/06 to discuss with staff the outcome of the state inspection findings. The Dir. of OP Services discussed the requirements of a treatment plan paying specific attention to frequency of treatment and type of services.
The Diir. of OP Services will review with staff on a weekly basis the treatment plans that are develop and insure that the treatment plans are in compliance. |
709.93(a)(9) LICENSURE Client records
709.93. 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
The aftercare plan was missing in client record #5. The aftercare plan did not include goals with time frames and support services in three of four client records, #6, 7 and 12.
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Plan of Correction
709.93(a)(9) The Project Director is responsible for quality assurance of cliens charts. The Dir. of OP Services
met with staff and reviewed the areas of non-compliance with staff. During supervision sessions with staff this form will be reviewed with clinician.
The Dir. of OP Services will meet with staff on a weekly basis.
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709.93(a)(10) LICENSURE Client records
709.93. 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 did not include reasons for this treatment experience and the client's response to their treatment plan goals in four of five client records reviewed, #5, 6, 7 and 12.
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Plan of Correction
709.93(a)(10) The Project Director
is responsible to insure proper way to fill out the client discharge summary. The Dir. of OP Services met with staff to discuss with staff the information relative to the client's involvement with the project. The discharge summary needs to include reasons for this treatment experience and the client response to the treatment
plan goals. The Dir. of OP Services will review with staff every two weeks
the discharge summary to insure proper completion of form. |