INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 24, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Wyoming Valley Alcohol and Drug Services 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on the review of six personnel records, the project failed to ensure that clinical supervisors and lead counselors, who have not functioning for two years as a supervisor in the provision of clinical services, complete a core curriculum in clinical supervision.
Employee #3 was promoted to a clinical supervisor on September 19, 2019 with no clinical supervision experience. There was no documentation of the completion of the core curriculum in the personnel file at the time of the inspection.
Employee #4 was promoted to a lead counselor on March 9, 2020 with no clinical supervision experience. There was no documentation of the completion of the core curriculum in the personnel file at the time of the inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Clinical Supervisor has completed the training since the inspection. The lead counselor is scheduled. Covid caused reschedules/cancellations. The CEO will inspect training manuals monthly to ensure all trainings required are complete. DDAP shared an online training with us so accessibility will no longer be an issue. This requirement has been discussed at our last supervisory meeting. It is rectified. |
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 the review of eight personnel records, the project failed to ensure that two employee received a minimum of six hours of HIV/AIDS and/or at least four hours of tuberculosis, sexually transmitted diseases and other health related topics training within the first year of employment.
Employee #5 was hired on December 30, 2019 and was due to have the communicable disease trainings no later than December 30, 2020; however, there was no documentation in the personnel file of the completion of the HIV/AIDS training as of the date of the inspection.
Employee #7 was hired on December 16, 2019 and was due to have the communicable disease trainings no later than December 16, 2020; however, there was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
The findings were reviewed with project staff during the licensing process.
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Plan of Correction
This has been discussed with the employees in question. Unfortunately, their trainings scheduled were cancelled/rescheduled due to COVID. Clinical Supervisor will monitor training manuals on a monthly basis so that necessary trainings are scheduled and completed. We are aware of online availability now as well. In addition, these requirements are discussed in staff meetings and individual supervision with counselors. They have been scheduled. |
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 a review of client records, the project failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in one of fourteen client records reviewed.
Client #8 was admitted on May 5, 2020 and was active at time of inspection. A release of information form to the client ' s employer, signed and dated by the client on May 4, 2020, allowed for the release of client prognosis, nature of project, brief description of client progress and short statement as to whether the client has relapsed and the frequency of such relapse, all of which exceeds the limits established by 4 Pa. Code 255.5.
The findings were reviewed with project staff during the licensing process.
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Plan of Correction
This issue has been discussed with all staff in staff meetings, individual supervision, and email. This will alleviate this specific issue. In addition, the CEO will hold sporadic confidentiality trainings for all staff to keep updated confidentiality regulations fresh. In addition, weekly chart reviews are done by administration to ensure forms are properly filled out. Clients affected by this signed new forms and were explained what we can released per regulation. Old release forms are now void. |
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 the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included purpose of disclosure in four of fourteen client records reviewed.
Client #1 was admitted on September 16, 2020 and was a current client at the time of the inspection. A release of information form to the client ' s attorney, signed and dated by the client on January 5, 2021, did not document the purpose of disclosure.
Client #2 was admitted on November 19, 2020 and was a current client at the time of the inspection. A release of information form to the client ' s family member, signed and dated by the client on November 20, 2020 did not document the purpose of disclosure.
Client #3 was admitted on December 28, 2020 and was a current client at the time of the inspection. A release of information form to the client ' s attorney, signed and dated by the client on December 29, 2020, did not document the purpose of disclosure.
Client #13 was admitted on July 30, 2020 and discharged on September 22, 2020. A release of information form to the Department of Transportation, signed and dated by the client on July 21, 2020, did not document the purpose of disclosure.
The findings were reviewed with project staff during the licensing process.
This is a repeat citation from last year's licensure renewal inspection.
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Plan of Correction
This issue has been discussed with staff via meetings both individual and group. The clinical supervisor has discussed this issue with all clinicians. This issue will continue to be addressed in individual supervision and staff meetings to ensure it does not occur. In addition, the CEO will hold sporadic confidentiality trainings with staff to ensure compliance. Finally, weekly chart reviews are now completed by Administration to ensure compliance. New release forms were signed and explained to these clients. Old forms are now void. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on the review of client records and the client record of service, the project failed to provide individual counseling at least twice weekly in two of seven applicable client records reviewed.
Client # 1 was admitted on September 16, 2020 and was a current client at the time of the inspection. The project failed to document in the client record one of the two required individual counseling sessions for a partial hospitalization program for the weeks of October 4, 2020 through October 10, 2020, October 11, 2020 through October 17, 2020, October 18, 2020 through October 24, 2020, October 25, 2020 through October 31, 2020, November 22, 2020 through November 28, 2020, November 29, 2020 through December 5, 2020, December 6, 2020 through December 12, 2020, December 13, through December 19, 2020, December 20, 2020 through December 26, 2020, December 27, 2020 through January 2, 2021, January 3, 2021 through January 9, 2021, January 10, 2021 through January 16, 2021, January 17, 2021 through January 23, 2021, January 31, 2021 through February 6, 2021.
Client # 2 was admitted on November 19, 2020 and was a current client at the time of the inspection. The project failed to document in the client record one of the two required individual counseling sessions for a partial hospitalization program for the weeks of December 13, 2020 through December 19, 2020 and December 27, 2020 through January 2, 2021 and two of the two required individual sessions for the weeks of November 22, 2020 through November 28, 2020, November 29, 2020 through December 5, 2020 and December 6, 2020 through December 12, 2020.
The findings were reviewed with project staff during the licensing process.
This is a repeat citation from last year's licensure renewal inspection.
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Plan of Correction
This has been discussed with staff at last staff meeting by Clinical Supervisor. Clinicians have been told to block off time in schedules to ensure clients are seen twice weekly for individual sessions if client is in partial. This will also be monitored by administration through schedule checks and weekly chart reviews. This will also continue to be a point of topic in supervision meetings and staff meetings. |