INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on January 7, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, A Better Today, Inc. 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
|
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
|
Observations
During a licensing inspection conducted on January 7, 2020, the facility failed to provide documentation of at least nine months of close supervision for employee # 5.Employee # 5 was hired as a counselor assistant on September 21, 2018 with an associate degree. Employee # 5 did not receive nine months of close supervision. The last documented supervision occurred in November 2018.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
In accordance with 704.9(c), the Clinical Director will ensure any employee that is hired has the proper supervision requirements based off of DDAP regulations for supervision for counselor assistants based upon experience/degree-ongoing.
The Clinical Director will ensure the proper documentation of supervision is being done whether it is the Clinical Director supervising said employee or a lead counselor supervising-on going. |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
|
Observations
During a licensing inspection conducted on January 7, 2020, the facility failed to obtain a complete informed and voluntary consent to disclose form to include the name of the person, agency or organization to whom disclosure is made. Client # 8 was admitted on February 4, 2019 and discharged on May 1, 2019. An informed and voluntary consent to disclose form signed and dated on February 4, 2019 allowed for the release of presence in treatment, copy of the bill, and diagnosis, however did not provide the name of the person, agency or organization to whom disclosure is made. The findings were discussed with project staff during the licensing process.
|
Plan of Correction
In accordance with 709.28(c)(1), no consent form should be in the chart signed or unsigned by the client that does not specify name of the person, agency, or organization to whom disclosure is made.
For Client #8, that consent form has been removed from the chart and properly shredded in the facilities confidential Shred-It box. It was blue noted that the release has been removed.
The Clinical Director will ensure that no consent forms are in the charts that do not specify whom in which the disclosure is for. Monitoring of this is ongoing.
|
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
|
Observations
During a licensing inspection and review of the project's policy and procedure manual on January 7, 2020, the project was found to not be following their policy and procedure to include written acknowledgement of the client rights to be provided to the client upon admission. The findings were discussed with project staff during the licensing process.
|
Plan of Correction
In accordance with 709.30(1), to be in accordance with the facility's policy and procedure, the Clinical Director is creating a Client Rights form that will be given to each client at admission to review and sign. A copy will be given to each client as well as one copy will be in the chart. This will give the acknowledgement that the client is aware of their rights and given a copy. The clients rights will also be posted in each office for viewing purposes.
Client Rights form will be implemented in each office/client chart by 2/14/2020. The Clinical Director is responsible for this action.
|