INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 9-10th 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, My Sister's Place Thomas Jefferson University 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 (SRFSR) form, the facility failed to ensure that employee's #6 and #7 received the minimum 4 hours of TB/STD and other health related topics within the regulatory timeframe.Employee #6 was hired as a residental staff member on June 10, 2017 and was due to have the communicable disease trainings no later than June 10, 2019 . There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.Employee #7 was hired as a residental staff member on May 30, 2017 and was due to have the communicable disease trainings no later than May 30, 2019. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Administrative Assistant will create a document to track required employee trainings and required regulatory time frames. The Operations Director will check in with Administrative Assistant for the first three months to ensure utilization of tracking and deadlines are met. After the first three months, the Operations Director will audit Administrative Assistant's tracking twice a year. Employee #7 is scheduled to attend the required training on 2/26/2020. Employee #6 has attended the required training on 4/20/18. However, the certificate was not obtained and therefore not in her employee file. After the inspection, we were able to locate the certificate and forwarded to licensing specialist. |
711.53(c)(2)(iii) LICENSURE Purpose of Disclosure
711.53. 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:
(iii) The purpose of disclosure.
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Observations
Based on a review of seven client records, the facility failed to ensure that all consent to release forms contained the purpose for disclosure in two client records. Client record#1 was admitted on May 20, 2019 and was an active client as of the date of the inspection. A consent to release form was signed and dated on May 30, 2019 to a caseworker that failed to include the purpose of the disclosure.Client Record# was admitted on April 29, 2019 and was discharged on June 3, 2019. A consent to release form was signed and dated on April 29, 2019 to a county offical that failed to include the purpose of the disclosure. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Clinical Supervisor will review all aspects of consent forms with necessary staff to ensure that all components are completed. Clinical Supervisor will review with necessary staff during group supervision. Therapists will be responsible for auditing their own charts to ensure that all required sections are completed on consent forms. Therapists will also be responsible to complete new consents for consents that are not completed properly. Clinical Supervisor will conduct random chart inspections ongoing to ensure all aspects of consent forms are completed. |