INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 6 - 7, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Another Way, Inc. 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 November 4, 2008.
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Plan of Correction
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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
Based on a review of CPR certifications and conversations with facility staff on 10-6-08 and 10-7-08, the facility failed to provide sufficient staff who are CPR certified.
Finding:
The facility did not have sufficient staff trained in CPR. There is one staff member, personnel record #6, who works a weekend day shift and weekdays second shift that does not have a current CPR certification.
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Plan of Correction
CPR training is scheduled for all support staff members on November 22, 2008. Training being provided by Community Action in Uniontown.
We will be training everyone at the same time so that certifications can be managed by the administration department a little more effectively.In the past they were independantly done and staff was to maintain their own certifications. |
709.28(c) 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:
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Observations
Based on a review of the three client records on 10-7-08, the facility failed to provide an informed consent to release information to clients in three of three client records where required. The facility failed to provide signed consent to release information forms, and correctly completed consent to release information forms in three of three client records.
Finding:
All three client records included consent to release information forms that did not list the specific information that would be released. The specific information section of the form was left blank. In addition, the specific information section of the form includes an "other" option that when completed stated "relevant information necessary to obtain public assistance."
Client record #1 contained consent to release information forms where the purpose section of the form was left blank; the consent to release information forms were to a pharmacy, the clients mom and the clients dad. The witness signature was missing on a release of information to the Probation Office. There was a "Week that Was" form completed by the client that included another client's full name.
Client record #3 included a release form where the specific information section and the purpose section was left blank. There was documentation of information that was disclosed to Washington County SCA, the Drug Court, the Probation office, and Domestic Relations but there were no corresponding consent to release information forms that documented the client's permission to release information to any of those agencies.
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Plan of Correction
Staff training was provided on 10/30/2008 on completing a consent form. Staff was trained in various areas of the consents forms such as dates, purpose and signatures.
Chart Audits will be done by by the clinical department to help review client paperwork to ensure that no other client names appear in any other clinical documentation. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of the three client records on 10-7-08, the facility failed to provide a physical examination in two of the three client records where required.
Finding:
The facility failed to follow the program policy that states each client will have a documented physical examination. Client records # 2 and 3 did not have a physical examination documented.
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Plan of Correction
Prior to an admission Administrator and Lead Therapist will request the physical examination from treatment center, if not available client will be transpored to a local physician and have completed the first week of admission. |