INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 13, 2018 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 to not 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(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
The facility failed to collect feedback on completed trainings in two out of four staff records reviewed. Staff #1 was hired on October 1, 1987 as Project Director and Facility Director had no feedback forms for trainings attended in the 2017 training year. Staff #2 hired on October 17, 2015 and currently in the role of Clinical Director, had one feedback form with no date or topic listed on the form. Staff #2 had no other feedback forms for the training year 2017. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
In accordance with 704.11 the Clinical Director will ensure that documentation of training certificates and collecting feedback on completed training is completed in each employee file within one week from the day of training. |
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
The facility failed to ensure that counselors received a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD training within the first year of employment. Staff #7 was hired on October 4, 2016 as a Counselor/Assessment Specialist and should have had his HIV/AIDS and TB/STD training no later than October 4, 2017. Staff #7 had his HIV/AIDS training on October 31, 2018 and his TB/STD training on September 26, 2018. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In accordance with 704.11 the Clinical Director will ensure that staff follow the appropriate General training requirements. Counselors and Counselors assistants will complete the mandatory 6 hours of HIV/AIDS and at least 4 hours of TB/STD within the first year of employment. All other staff will complete the training within the first 2 years of their employment.
Clinical Director is responsible for monthly review of staff charts and inform counselors of training they have received and training they need to complete for the year.
The clinical director will be responsible for implementing the certificate and training feedback forms in the staff chart when completed.
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709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
The facility failed to recognize the condition upon which consents will expire as provided for under 42 CFR in fourteen out of fourteen records. Client #1 was admitted to outpatient on June 17, 2018 and was still active at the time of the inspection. A signed consent to a county correctional facility dated June 27, 2018 specified that revocation of consent could only be made verbally or in writing to their counselor. Client #2 was admitted to outpatient on July 9, 2018 and was still active at the time of the inspection. A signed consent to a county correctional facility and the Department of Corrections dated July 9, 2018 specified revocation of consents could only be made verbally or in writing to their counselor. Client #3 was admitted to outpatient on August 29, 2018 and was still active at the time of the inspection. A signed consent to a MAT program dated August 29, 2018 specified revocation of consent could only be made verbally or in writing to their counselor. Client #4 was admitted to outpatient on August 22, 2018 and discharged on October 10, 2018. A signed consent to juvenile probation dated August 22, 2018 specified revocation of consent could only be made verbally or in writing to their counselor. Client # 5 was admitted to outpatient on August 28, 2018 and was discharged on October 20, 2018. A signed consent to a MAT program dated August 28, 2018 specified revocation of consent could only be made verbally or in writing to their counselor. Client # 6 was admitted to outpatient on September 14, 2018 and was discharged on November 3, 2018. A signed consent to a MAT program dated September 14, 2018 specified revocation of consent could only be made verbally or in writing to their counselor. Client #7 was admitted on September 13, 2018 and discharged on November 3, 2018. A signed consent to a MAT program dated September 13, 2018 specified revocation of consent could only be made verbally or in writing to their counselor. Client #8 had an Intake, Evaluation and Referral on September 11, 2018. A consent to a MAT program dated September 11, 2018 specified revocation of consent could only be made verbally or in writing to their counselor. Client #9 had an Intake, Evaluation and Referral on September 13, 2018. A signed consent to a MAT program dated September 13, 2018 specified revocation of consent could only be made verbally or in writing to their counselor. Client # 10 had an Intake, Evaluation and Referral on September 11, 2018. A signed consent to a MAT program dated September 11, 2018 specified revocation of consent could only be made verbally or in writing to their counselor. Client # 11 had an Intake, Evaluation and Referral on September 27, 2018. A signed consent to a MAT program dated September 27, 2018 specified revocation of consent could only be made verbally or in writing to their counselor. Client # 12 had an Intake, Evaluation and Referral on October 9, 2018. A signed consent to a MAT program dated October 9, 2018 specified revocation of consent could only be made verbally or in writing to their counselor. Client #13 had an Intake, Evaluation and Referral on October 23, 2018. A signed consent to a MAT program dated October 23, 2018 specified revocation of consent could only be made verbally or in writing to their counselor. Client #14 had an Intake, Evaluation and Referral on October 25, 2018. A signed consent to a MAT program dated October 25, 2018 specified revocation of consent could only be made verbally or in writing to their counselor. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In accordance with 709.28 the Clinical Director has already updated consents as of 11/3/2018 to recognize the conditions upon which consents will expire as provided for under 42 CFR. The consents have been updated to reflect that consents at any time may be revoked by notifying any counselor, support staff or administrator verbally or in writing, except to the extent that action has been taken in reliance on my consent. |