INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 7, 2007 to August 9, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Lebanon Treatment Center was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection and a plan of correction is due on September 4, 2007.
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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 facility failed to document individual training plans for 2007 in two of seven employee records reviewed, #11 and 12.
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Plan of Correction
A completed individual training plan has been created for each of the staff mentioned. The staff member's immediate supervisor will be responsible for creating an individual training plan with a new employee within the first week of employment.
Prior to January 1, annual training plans are completed by supervisor
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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
The facility failed to document fire extinguisher training in two of seven employee records reviewed, #5 and 6. Fire extinguisher training was not documented for employee #5 and documented late for employee #6.
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Plan of Correction
Safety Officer will ensure all new employees complete fire extinguisher training within 7 days of start date. Clinic Director will follow up to ensure compliance |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
The facility failed to document emergency training in two of seven employee records reviewed, #5 and 6. Emergency training was not documented for employee #5 and documented late for employee #6.
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Plan of Correction
Safety Officer will ensure all new employees complete emergency training within 7 days of start date. Clinic Director will follow up to ensure compliance. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
The facility failed to make the 2006 annual report available to the public.
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Plan of Correction
This was placed in the Lebanon Daily News on August 11, 2007: "The 2006 Annual Report of the Lebanon Treatment Center, a member of the CRC Health Group, is available for review at 3030 Chestnut Street, Lebanon, PA 17042." The Proof of Publication of Notice is kept on site at the Lebanon Treatment Center.
This process will be used for each annual report review. The clinic director will continue to monitor for compliance.
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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
The facility failed to document a discharge summary in one of three client records reviewed, #7.
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Plan of Correction
Discharge summaries are to be completed within 7 days following discharge. This procedure will be reviewed with the clinical staff by the clinical supervisor during the August 30th clinical group supervision meeting. This will be monitored for compliance by the clinical supervisor with discharge chart auditing. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
The facility failed to document follow up information as per agency policy in two of three client records reviewed, #6 and 7.
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Plan of Correction
Persons who have left the program before completing will be contacted within fourteen (14) days of leaving the project. This procedure will be reviewed with the clinical staff by the clinical supervisor during the August 30th clinical group supervision meeting. This will be monitored for compliance by the clinical supervisor with keeping a flow sheet for contact follow up, and documentation in the patient's file. This process will begin with the auditing of the discharge chart. |