INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 8, 2006 to May 9, 2006 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during the inspection and a plan of correction is due on June 15, 2006.
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Plan of Correction
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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
Employees 1, 3,5, and 6 did not have the required fire extinguisher training within 7 days of the date of employment.
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Plan of Correction
An approved 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
Employees #1, 3, 5, and 6 did not have the required emergency training.
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Plan of Correction
An approved Plan of Correction is on file with the Department of Health. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
One out of two charts contained a treatment plan update that failed to document the client's progress relative to the goals and objectives on the treatment plan.
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Plan of Correction
An approved Plan of Correction is on file with the Department of Health. |
709.26(d)(2) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(2) The results of reference investigations.
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Observations
Reference results were missing in employee personnel records #6, 5, 4, 3, and 1.
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Plan of Correction
An approved Plan of Correction is on file with the Department of Health. |
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
A re-disclosure statement included in the consent to release implies that once the information is released to the other party that confidentiality laws no longer apply to the information. Although the facility giving the information is not responsible if the agency re-releases the information once they have made them aware that it is illegal, the information is always protected. This form is giving the client to whom it pertains inaccurate information. This form was found in all client charts reviewed.
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Plan of Correction
An approved 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
Letters to probation officers documented in the client charts exceeded the parameters of 4 Pa. Code Subsection 255.5(b) with the inclusion of positive/negative drug screen information in the letters. This was found ion charts: #2, 8, 9, 10,11,and 13.
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Plan of Correction
An approved Plan of Correction is on file with the Department of Health. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Aftercare plans were missing in one out of two charts (client chart: #3).
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Plan of Correction
An approved Plan of Correction is on file with the Department of Health. |