INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 26, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Wellspan Philhaven 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:
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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 the facility's Staffing Requirement Facility Summary Report form, the facility failed to ensure that employees received the minimum of six hours of HIV/AIDS training and at least four hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #6 was hired as a counselor on February 28, 2022 and was due to have the communicable disease trainings no later than February 28, 2023. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
This requirement is already included in our training evaluation and planning for new hires and established employees. The training planning form explicitly indicates that the training is due within the first year of hire. The Facility Director meets with employees once a month to review resources needed including training plans. The clinician was not able to access the training via a DDAP approved trainer in the time frame. The counselor is currently enrolled to receive the training with DDAP on December 19, 2023. The Facility Director will continue to plan training with new hires. The Facility Director will work with the Director of Professional Development and the Single County Authority (SCA) to develop an internal organizational trainer to offer the required training should DDAP be unable to fulfill this role in the future. All new employees will complete the required DDAP mandatory training within one year of hire. The Facility Director will continue to plan training with new hires. The Facility Director will work with the Director of Professional Development and the Single County Authority (SCA) to develop an internal organizational trainer to offer the required training should DDAP not be able to fulfill this role in the needed timeframe in the future. All new employees who have not previously completed the required DDAP mandatory training will receive it within one year of hire. |
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 must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the specific information disclosed in client records #3 and #4.
Client #3 was admitted on May 8, 2023, and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated May 8, 2023 to the funding source and emergency contact did not include the specific information disclosed.
Client #4 was admitted on May 25, 2023 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information date June 12, 2023 to the emergency contact did not include the specific information disclosed.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Facility Director assigned a mandatory LMS training on accurate completion of the Release of Information for Substance Use Disorder information to all Front Office and Clinical Staff on 11/13/23. As of 11/17/23 all staff completed the training. This information will be reviewed in an All Staff Meeting on 11/30/23. minutes from the All-Staff meeting including this information will be available to staff who may not be present to review. This LMS module will be assigned to all new employees to complete within the first week of hire and listed on the on-boarding checklist. The Facility Director will review 5 random charts per month for accurate completion of the SUD Release of Information. Individual staff will receive educational coaching if this information is not included in the audit review. The SUD Release of Information will include the specific client information that will be disclosed in 100% of client charts for 3 consecutive months to assure compliance. Results will be shared quarterly with the system for accountability. |
709.28 (c) (3) 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 must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to ensure that all consent to release forms contained the purpose of disclosure in client records #4
Client #4 was admitted on May 25, 2023, and was still active at the time of inspection. A consent to release form was signed and dated on June 12, 2023, to the emergency contact that failed to document the purpose of disclosure.
These findings were discussed with Facility staff during the inspection process.
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Plan of Correction
The Facility Director assigned a mandatory LMS on accurate completion of the Release of Information for Substance Use Disorder information to all Front Office and Clinical Staff on 11/13/23. As of 11/17/23 all staff completed the training. This information will be reviewed in an All Staff Meeting on 11/30/23. minutes from the All-Staff meeting including this information will be available to staff who may not be present to review. This LMS module will be assigned to all new employees to complete within the first week of hire and listed on the on-boarding checklist. The Facility Director will review 5 random charts per month for accurate completion of the SUD Release of Information. Individual staff will receive educational coaching if this information is not included in the audit review. The SUD Release of Information will include the purpose of the disclosure in 100% of client charts for 3 consecutive months to assure compliance. Results will be shared quarterly with the team for accountability. |