INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 10, 2006 to May 11, 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 June 13, 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
Individual training plans were not completed for employees #1, 2 and 3.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
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
There was no documentation that employees #1 and 2, were instructed in the use of the fire extinguisher.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
1 out of 6 fire drills were documented since the previous licensing inspection in October 2005.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
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
There was no documentation demonstrating that employees #1 and 2 were trained to perform assigned tasks during emergencies.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
709.26(e) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
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Observations
The project was unable to demonstrate that employees were informed of their rights.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
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
In 2 out of 4 clinical charts reviewed, specifically #2 and 5, the consent to release information forms used to release information to the Lancaster County SCA exceeded the parameters of 4 Pa. Code subsection 255.5(b).
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
In clinical charts #1, 2, 3 and 5, the psychosocial evaluations did not address all the required areas. In addition, the evaluations were brief reiterations of the history with little to no clinical impressions.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
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
In 2 out of 4 clinical charts reviewed, specifically #1 and 5, the treatment plan updates were missing. However, in clinical charts #2 and 4, the treatment plan updates were detailed and timely.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |