INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 29, 2006 and November 30, 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 January 5, 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
The project failed to define potential training resources on individual training plans reviewed during the survey.
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Plan of Correction
An individualized training form has been designed by the Executive Director. Beginning 6/30/07-6/30/08 annual training year individualized training plans will be completed by the Executive Director, Linda Franiewski, for each employee
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705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
The project failed to document hot food temperatures are at or above 140 degrees Fahrenheit..
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Plan of Correction
Effective during the 11/27/06 - 11/30/07 State licensing visit, a form was created by the cook, Chuck Justes, which documents and records the hot food temperature by the individual preparing the meal to ensure that food temperature are at or exceeds 140 degrees Fahrenheit. The Cook will be the individual ensuring that this log is properly maintained. |
705.10 (b) (1) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(1) Maintain a minimum of one operable, automatic smoke detector on each floor, including the basement and attic.
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Observations
The project failed to maintain an operable automatic smoke detector in the attic of the facility.
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Plan of Correction
The Executive Director filed an exception request with The Department on 1/18/07. In the event the exception request is denied, the Executive director will be the employee responsible for ensuring that a smoke detector is installed in the attic crawl space within 90 days from the licensing visit. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
The project failed to document and conduct a fire drill during sleeping hours every six months.
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Plan of Correction
Effective immediately following the 11/27-11/30/06 state licensing visit, all support staff was instructed by the Executive Director and the Support Staff Manager to conduct fire drills both during sleeping hours as well as all other times during the day. Fire drill reports are completed for each fire drill. The Support Staff Manager will the employee responsible for ensuring that fire drills are performed accordingly. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
The project failed to develop confidentiality procedures that comply with 4 Pa. Code subsection 255.5. The project defined procedures in regard to a "Duty to Warn" and also utilize a "Qualified Service Organization Agreement" inappropriately for that purpose.
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Plan of Correction
Immediately following the 11/27/06 - 11/30/06 licensing visit the Exectuve Director has re-written and re-defined the Gaiser Center's procedure for handling certain life-threatening situations that involve a clear and imminent danger that a client may inflict serious bodily harm on another person or pesons. The new policy recognizes these situations as "Medical emergencies" and requires that staff take all necessary actions to protect the life of the Also,immediately following the 11/27/06 - 11/30/06 licensing visit , the executive Director destroyed and revoked the inappropriately used Qualified Service Organization Agreements. |
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
The project failed to obtain an informed and voluntary consent in client record number 2044. Three consents were signed but were incomplete, failing to include the information to be released and the purpose of release.
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Plan of Correction
Immediately following the 11/27/06 - 11/30/06 licensing visit the Exectuve Director and Clinical Director held a staff meeting with all clinicians on the correct procedure of obtaining an informed and voluntary consent. Each clinician will be responsible for the correctness and completeness of their clients' informed and voluntary consents. |
709.32(c)(3) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(3) Inspection of storage areas.
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Observations
The project failed to provide written documentation of inspection of medication storage areas. Inspection records were not provided for the months of September, October, November and December of 2005.
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Plan of Correction
Effective immediately following the 11/27 - 11/30/06 State licensing visit the medication inspection policy was reviewed with the RN and the Executive Director.The Gaiser Center R.N. is the employee responsible for performing a monthly inspection of the medication storage area. The Executive Director will sign the monthly inspection report |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. 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
The project failed to document an individualized treatment and rehabilitation plan.
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Plan of Correction
On Wednesday December 6, 2009 all clinical employees were staffed by the Clinical Director and Executive Director regarding the individualized treatment plans. The client's primary therapist is the employee responsible for ensuring thattreatment plans will incorporate self-reported Client Goals for Treatment. In addition, the Clinical Director and the Executive Director will monitor treatment plan quality during weekly clinical staffing held every Wednesday. |
709.52(e)(1) LICENSURE Medical/dental support services
709.52. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(1) Medical/dental.
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Observations
The project failed to document a letter of agreement for dental support services.
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Plan of Correction
On Janaury 4, 2007 The executive Director of the Gaiser Addiction Center has negotiated with United Dental of Butler to enter into a service agreement whereby United Dental agrees to provide general dental and emergency dental care to Gaiser Clients. The Executive Director will ensure that this agreement remains in effect. |
709.52(e)(3) LICENSURE Legal support services
709.52. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(3) Legal.
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Observations
The project failed to provide documentation of legal support services.
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Plan of Correction
On January 2, 2007 the Gaiser Addiction Center and Neighborhood Legal Services of Butler have entered into a service agreement whereby NLSA agrees to provide necessary legal services to Gaiser Clients. The Executive Director is the employee responsible for implementing and monitoring this contract. |
709.52(e)(4) LICENSURE Economic support
709.52. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(4) Economic.
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Observations
The project failed to proved documentation of economic support services.
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Plan of Correction
On January 4, 2007 the Gaiser Addiction Center and CCS of Western Pennsylvania have entered into a service agreement whereby CCS Western Pa agrees to provide necessary credit counseling services to Gaiser Clients. The Executive Director is the employee responsible for implementing and monitoring this contract. |
709.51(e)(5) LICENSURE Educational support
709.52. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(5) Educational.
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Observations
The project failed to provide documentation of educational support services.
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Plan of Correction
On Janaury 4, 2007 The executive Director of the Gaiser Addiction Center has negotiated with Office of Vocational Rehabilitation to enter into a service agreement whereby OVR agrees to provide both educaitonal and vocational support to Gaiser Clients. The Executive Director will ensure that this agreement remains in effect.
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709.52(e)(6) LICENSURE Vocational Support services
709.52. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(6) Vocational.
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Observations
The project failed to provide documentation of vocational support services.
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Plan of Correction
On Janaury 4, 2007 The executive Director of the Gaiser Addiction Center has negotiated with Office of Vocational Rehabilitation to enter into a service agreement whereby OVR agrees to provide both educaitonal and vocational support to Gaiser Clients. The Executive Director will ensure that this agreement remains in effect.
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709.53(a)(8) LICENSURE Case Consultation Notes
709.53. 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
Case consultation documents failed to include the names and disciplines of the persons attending the consult.
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Plan of Correction
Effective immediately following the the 11/27/07/11/30/07 State licensing visit, all names and disciplines of staff present during consult will be included on the consult and maintained in the client's permanent chart. The Clinical Director will be the employee responsible to ensure that that names appear and disciplines appear on case consults going forward. |