Plan of Correction

1) According to NJAC Title 10:161B-3.5(a),(f)1 The facility shall maintain

personnel records for each employee, including, but not limited to, . . .
documentation of staff orientation and staff education received, . . .
emergency plans and procedures, infection prevention and control program,
universal precautions and policies/procedures concerning conflicts of
interest, ethics, etc.
All employees receive annual training that includes the general requirements
outlined in the Licensure Standards. The deficiencies were for the agencys
CEO and one employee who was rehired following a period of employment
elsewhere. To prevent this deficiency from occurring again, the Human
Services Director will require that all employees receive orientation training
within 90 days of hire and documentation of orientation and staff education
will be maintained in personnel records for each employee. HR will also send
reminders to the employees every year to submit verification of annual inservice education.

2) Title 10:161B-3.6 Policy and procedure manual stipulate that (a) The
administrator shall develop, implement and ensure the review, at least
annually, of a policy and procedure manual(s) about the organization and
operation of the facility and (ii) Comply with client care policies and
procedures, and not violate client rights, nor be used as a tool to punish or
coerce clients.
An executed document stating that the Policy and Procedure manual shall be
reviewed at least annually by the Behavioral Healthcare Continuous Quality
Improvement Committee as approved by the governing authority presiding
officer will be posted in the procedure manual and will be available and
accessible to all patients, staff and the general public during the CFS hours
of operation. This will be done on April 30, 2015.

3) 10:161B-3.7 Employee health (a) The policy and procedure manual shall
include policies and procedures to ensure that physical examinations of staff
are performed upon initial employment and at subsequent intervals. Policies
and procedures shall specify the circumstances under which other persons
providing direct client care services shall receive a physical examination.
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Plan of Correction
Policies and procedures shall specify the content and the frequency of the
examination. (d)6. The Mantoux skin test shall be repeated on an annual
basis for all employees unless contraindicated.
All new hires are required receive and produce documentation of a physical
examination including current vaccinations outlined in the Licensure
Standards. As of April 10, 2015, copies of all employee physical records will
be kept in their personnel file with the Human Resources Director. To
prevent this deficiency from reoccurring, the Human Services Director will
send reminders to the staff every other year to submit verification of
current licenses/certifications and physical exams indicating current
vaccinations.
4) 10:161B-3.7 (d) 6 Employee health The Monteux skin test shall be
repeated on an annual basis for all employees unless contraindicated.
All new hires are required to receive and produce documentation of a
physical examination including current vaccinations outlined in the Licensure
Standards. As of April 30, 2015, copies of all employee physical records will
be kept in their personnel file with the Human Resources Director. To
prevent this deficiency from reoccurring, the Human Services Director will
send reminders to the staff every other year to submit verification of
Monteux testing.
5) 10:161B-9.2 Client treatment planning (a) A client treatment plan shall be
developed for every client based on the assessment of the client in
accordance with N.J.A.C. 10:161B-9.1. ix. Long and short term goals with
timeframes for achievement.
The Center for Family Services Substance Abuse Treatment Plan has been
amended to include long and short term goals with a time frame for
achievement of 30 days or less for short term goals and 30 Days or More
for long term goals. This amended Treatment Plan will be available for all
new clients as of April 30, 2015.