INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on November 5,2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, York Hospital Behavioral Health Services was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
|
Plan of Correction
|
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
|
Observations
Based on a review of personnel records, the facility failed to document 25 clock hours of annual training for the counselors.
The findings include:
Four personnel records were reviewed on November 5th, 2015. Two out of four personnel records pertained to counselors and were reviewed for annual training. The facility's training year is from September through August. The facility failed to document 25 clock hours of annual training for employee #3 for the September 1, 2014 - August, 2015 training year.
Employee # 3 is a counselor and was hired on July 2009. Employee record # 3 only contained documentation of 24 clock hours of annual training for the September 1, 2014 - August, 2015 training year.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
After examination of the Counselor (Employee #3) personnel record, it was determined the counselor did have sufficient CEU?s for the referenced training year, however there was one training certificate missing from the file, that was later found. Personnel files will be reviewed quarterly by an administrative staff member to assure each counselor is on target to complete 25 hours of training annually and the applicable documentation for these trainings is incorporated into their personnel file |
711.91(b)(4) LICENSURE Consent to Treatment
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
|
Observations
Based on a review of client records, the facility failed to document a consent to treatment in one of seventeen client records.
The findings include:
Seventeen client records were reviewed on November 5, 2015. Client #8 was admitted on August 27, 2014. The facility failed to have a signed consent to treatment on file in record #8.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The current medical record includes electronic and paper documentation. The consent to treat for Client #8 is on file in the scanned area of the electronic patient record but was not readily located to present during the record review. During our next review we will have a designated staff member present to work collaboratively with the Licensing Specialist during the record review to assure all required elements, including the consent to treat is presented for review. This will allow us the opportunity to identify and address immediately any documentation in question prior to the exit interview. |
711.93(c)(2) LICENSURE Consent to Release-Informed & Voluntary
711.93. Client records.
(c) Confidentiality.
(2) 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:
|
Observations
Based on a review of client records, the facility failed to obtain informed and voluntary consents in two of seventeen records reviewed.
The findings include:
Seventeen client records were reviewed on November 5, 2015. All were reviewed for informed and voluntary consent forms. The facility failed to document informed and voluntary consents in three client records, specifically record, #4 and 9.
Client #4 - Consent to release dated July 13, 2015 for the client's probation officer failed to have the purpose of the release documented. The facility checked the other box and failed to document what other meant pertaining to the purpose of the release.
Client #9 - A letter dated August 10, 2015 addressed to " Whom it may concern " had identifying information about client #9 with no consent to release on file for " Whom it may concern " .
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Facility Director will communicate regulations 711.93 (C) (2) to staff via email and staff meetings reminding them a valid consent for Release of Information must be obtained and include the specific information to be disclosed and that all communication must include the name of the person, agency, or organization to whom disclosure is made. Random chart audits will be conducted to monitor compliance. |