INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 22, 2025, 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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704.11(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 the Staffing Requirements Facility Summary Report (SRFSR) and discussion with the facility director, the facility failed to ensure that staff persons 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 Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment.
Employee #11 was hired as a counselor assistant on March 20, 2023 and was still in the position at the time of the inspection. There was no documentation in the personnel file that TB/STD training had been completed.
This is a repeat citation from the February 5, 2024 inspection.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
This has been addressed in several ways. A staff meeting was held to remind all employees about the necessary trainings that need to be completed in a period of specified time. In addition, this will be discussed with employees during their supervision meetings which are held consistently. Training manuals will be reviewed at least once monthly by the Clinical Supervisor to ensure compliance. The training missing by the employee mentioned will be scheduled ASAP to suffice the requirement. |
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 facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in one out of seven records reviewed.
Client #2 was admitted on February 21, 2024 and was still active at the time of the inspection. A consent form signed and dated February 21, 2024, for a family member, failed to include the purpose of disclosure.
This is a repeat citation from the February 5, 2024 licensing inspection.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The new and proper release form will be signed by the client and counselor at client's next session. In addition, a staff meeting was held to discuss this issue. Also, confidentiality and proper releases will be reviewed at all Supervisory meetings which are held consistently. This will minimize or eliminate this problem going forward. It has been addressed. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of the client records, the facility failed to document that a copy of a client consent shall be offered to the client and a copy maintained in the client record in one out of seven client records reviewed.
Client #2 was admitted on February 21, 2024 and was still active at the time of the inspection. A consent form signed and dated February 21, 2024, for a family member, did not have documentation that the client was offered a copy of the consent form.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The new and proper release form will be signed by the client and counselor at client's next session. In addition, a staff meeting was held to discuss this issue. It has been made clear by the Supervisor that evidence on whether or not a client accepted a copy of a form is documented. In addition, this will be addressed at Supervisory meetings with each employee to ensure this is completed with each client. |