INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on October 22-24, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Habit OPCO, Inc. - Allentown 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of personnel and training records, the facility failed to ensure that staff persons and/or volunteers received 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 as per the regulatory requirements in one of five personnel training records reviewed.
The findings include:
Five personnel training records were reviewed October 22, 2013 for documentation verifying the completion of the mandatory HIV/AIDs and TB/STD training. One of five lacked documentation that the training was completed as per the regulatory requirements.
Employee # 7, counselor, was hired on June 24, 2011. Employee # 7 was required to obtain 6 hours of HIV/AIDS training and 4 hours of TB/STD training by June 24, 2012. The training was not documented as of the date of the inspection.
|
Plan of Correction
Director of PA Operations met with the Clinical and Medical Director to discuss deficiencies in regulation 704.11(c) (1). The Medical Director will provide 6 hours of HIV/AIDS training, and at least 4 hours of tuberculosis/sexually transmitted disease training using a Department approved curriculum.
The training will be available to all staff members who are in need of the required trainings and completion will be clearly documented in all personnel files as required by Drug and Alcohol licensure regulations.
Trainings will be completed by December 31, 2013 and certificates of completion will be placed in employee files as proof of their completion.
|
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:
|
Observations
Based on the review of client records, the facility failed to ensure all consents to release information was properly completed in five of fifteen client records reviewed.
The findings include:
Twenty four client records were reviewed October 22-24, 2013. Fifteen client records were reviewed specifically for properly completed consents to release information.
Client record # 8 contained several consents to release information that were improperly completed for the purpose of the release. On May 23, 2013 a consent to release information was completed for another treatment provider that was restricted to 4 PA Code 255.5. On September 11, 2013 a consent to release for a governmental agency was initiated that allowed only the treatment status to be released without allowing for the presence in treatment or the nature of the treatment, which was released.
Client record # 10 contained a consent to release information to another narcotic treatment provider that was not sufficient to cover the information sent. There was also a consent for a governmental agency that was not signed by the client as required.
Client record # 13 contained three consents not signed by the client or a witness.
Client record # 14 contained two consents to release that were not signed by the client or the witness.
Client record # 17 contained documentation of information released that exceed what the consent to release allowed.
|
Plan of Correction
Director of PA Operations addressed deficiencies found in regulation 709.28(c) with the Clinical Director and the Lead Clinician, in regards to Confidentiality. Findings will be shared with the clinical staff during the next group supervision scheduled for November 14, 2013. Training on confidentiality and consent to release information will be arranged and provided to all clinical staff members no later than December 31, 2013. The training will give clinicians insight into regulatory guidelines of 42 CFR 2.22, and will include the restrictions of 4 PA Code 255.5, and the proper completion of consents to release information.
Furthermore, transfer fax sheets will have a check off box to include all documentation sent in accordance with regulation 715.20.
The Clinical Director and Lead Counselor will monitor the accuracy of consents to release patient information through regularly scheduled individual and group supervision, as well as cart reviews paying close attention to consents.
|