INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 6 and August 7, 2009 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 August 31, 2009.
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and staff interview on August 6,2009, the facility failed to ensure that staff persons received a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD and other health related topics within two years of employment for non-clinical staff.
The findings include:
On August 6, 2009 nine staff records were reviewed. Seven staff were required to have completed at least 6 hours of HIV/AIDS and at least 4 hours of TB/STD training. Four support staff were missing documentation of at least six hours of HIV/AIDS training. The Clinical Supervisor informed the licensing specialists that staff #'s 6,7,8, and 9 did not complete HIV/AIDS training as of the date of inspection. Three support staff were missing documentation for at last four hours of TB/STD training. The Clinical Supervisor informed licensing specialists that staff #'s 7,8, and 9 did not complete TB/STD training as of the date of inspection.
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Plan of Correction
Staff in need of training have been scheduled for approved trainings on HIV on 9/10/2009, and TB/STD on 9/24/2009. New staff to the program will be scheduled for approved trainings on HIV/ TB/STD as soon as possible, not to be over a year. Clinical Supervisor will monitor for compliance. Full compliance will be achieved by 9/30/3009. |
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
Based on a review of Fire Drill Records on August 6, 2009 the facility failed to document monthly fire drills.
The findings include:
On August 6, 2009 fire drill records were reviewed. A fire drill was not documented for December 2008.
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Plan of Correction
Monthly fire drills will occur. Front office manager will be conducting fire drills, and nursing supervisor will monitor for ongoing compliance. Full compliance will occur in 8/2009. |
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
Based on a review of client records on August 6, 2009 and August 7, 2009, the facility failed to ensure that staff notified a client in writing of a decision to involuntarily terminate client's treatment at the project in 1 of 1 client record.
The findings include:
On August 6, 2009 and August 7, 2009 15 client records were reviewed. One client record was required to have a written notification of a decision to involuntarily terminate the client's treatment.. A written letter of termination was not documented in client records # 9.
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Plan of Correction
Letters of notification of treatment termination are policy for all involuntary termintations. This letter will be used upon discharge of any involuntary patient. Clinical staff have received training on the process at clinical team meeting on 8/13/2009. Clinical Supervisor will monitor for compliance, and full compliance will occur in 8/2009. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records on August 6,2009 and August 7, 2009, the facility failed to ensure that case consultations were completed in accordance with facility policy in 7 out of 15 client records.
The findings include:
On August 6, 2009 and August 7, 2009 15 client records were reviewed. Fifteen client records were required to have a completed case consultation. A case consultation was not documented in client records # 1, 4, 8, and 13. Case consultations were documented late in accordance with facility policy to complete a case consultation within 90 days of admission in client record # 2, 5 and 14.
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Plan of Correction
Case consultations are due every 90 days for the first year per policy. This process has been reviewed with clinical staff in clinical supervision on 8/14/2009. Clinical Supervisor will monitor for compliance and full compliance will occur in 8/2009. |
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
Based on a review of client records on August 6,2009 and August 7, 2009, the facility failed to ensure that discharge summaries were completed as per facility policy in 3 out of 7 client records.
The findings include:
On August 6, 2009 and August 7, 2009 15 client records were reviewed. Seven client records were required to have a completed discharge summary. A discharge summary was documented two months post discharge in client record # 13. The reason for treatment simply listed drug and/or alcohol dependence in client records # 10 and 14.
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Plan of Correction
Policy is for the completion of discharge summaries within 7 days of discharge. Clinical staff received review of the policy on 8/14/2009. Clinical Supervisor will monitor for compliance and full compliance will occur in 8/2009. |