INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on November 18, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, A Better Today, Inc. Satellite Hazleton was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
|
Plan of Correction
|
704.2(b) LICENSURE Staffing Plan
704.2. Compliance plan.
(b) The plan documenting the qualifications and training of staff shall be presented to Department licensing representatives at the time of the project's site visit.
|
Observations
The plan documenting the qualifications and training of staff that was submitted during the presubmisison process was inaccurate and incomplete. While onsite, the facility was given an opportunity to correct the form, and the forms had to be returned to the provider again due to undocumented staff and other inaccuracies.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
By 11/29/16, the A Better Today Clinical Director will take complete responsibility of the pre-submission of the qualifications and training of staff. During the site visit, the ABT clinical director identified the existing errors and was trained on the full and accurate completion of the pre-submission of the qualifications and training of staff. The ABT clinical director will pursue further on-line training from the DOH website and will update the qualifications of staff and training grid quarterly. |
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 the review of personnel records, personnel record #4 did not contain documentation of tuberculosis, sexually transmitted disease (TB/STD) training within the required time frame.
Employee #4 was hired September 28, 2015 as a counselor assistant and was still in that position as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
On December 9, 2016, the ABT clinical director identified and notified all ABT staff members required by regulation to complete TB/STD training within their first year of employment. The identified staff members, including staff member #4, were provided the training date of February 23, 2017.
On January 2, 2017, the ABT clinical director will complete the annual staff training calendar which will ensure that all ABT staff will be cognizant of all DDAP required trainings and dates, including TB/STD training dates. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
|
Observations
Based on a review of personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of one personnel records reviewed.
Four personnel records were reviewed on November 14, 2016, one of which was identified as a counselor. Employee #3 was hired as a counselor on January 21, 2013. The facility training year is from January through December. The training year for January 2015 to December 2015 was reviewed. Employee #4 only had documentation of CPR training, and no other hours of annual training were noted in the record.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
By 12/5/16, the A Better Today Clinical Director will review with all ABT staff, including employee #3, the Department of Drug & Alcohol Programs regulatory requirement of 25 hours of training per calendar year, in the identified training areas.
Additionally, by 12/5/16, all ABT staff, including employee #3, will attend a policy training on required trainings and timelines, ensuring all ABT staff will complete required trainings in 2016.
On January 2, 2017, the ABT Clinical Director will create the training calendar for 2017 identifying training needs for all ABT staff. |
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.
|
Observations
Ten client records were reviewed on November 18, 2016. The facility failed to obtain an informed and voluntary consent in one of twelve client records reviewed.
Client #8 was admitted into treatment on March 21, 2016 and was discharged on August 21, 2016. The record contained a consent to release information form to an agency, dated March 21, 2016, which identified that the following information was permitted to be released: attendance, diagnosis, cooperation with treatment program and prognosis. The client record contained documentation that information was released that exceeded what was permissible by the consent on April 19, 2016, May 18, 2016, June 8, 2016 and June 23, 2016. Specifically, the client's progress in treatment, medical issues and the condition of their home environment.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
By 12/5/16, the ABT clinical director will meet with all ABT staff members to provide a training on confidentiality and how to properly complete a consent to release information. this training will continue at each ABT site six months from this date. In addition, all ABT clinical staff members will be required to attend and complete a DDAP approved external training on confidentiality and the application of confidentiality. The ABT clinical director will review client records for accurate and complete consent to release information forms at each site on a quarterly basis.
Due to the discharge status of client #8, in-person corrective action was not possible. |
709.93(a) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
|
Observations
Based on a review of client records, the facility failed to document a complete client record in five of ten records reviewed.
Ten client records were reviewed on November 18, 2016 six of which required documentation of follow up information and case consultations.
Client records #5, #6, #8, #9 and #10 failed to include documentation of a follow up.
Client #5 was admitted on February 12, 2016 and was discharged on July 12, 2016. There was no documented follow up.
Client #6 was admitted on January 20, 2016 and was discharged on June 20, 2016. There was no documented follow up.
Client #8 was admitted on March 21, 2016 and was discharged on August 21, 2016. There was no documented follow up.
Client #9 was admitted on December 23, 2015 and was discharged on July 6, 2016. There was no documented follow up. Additionally, the client record contained case consultations dated December 23, 2016, April 23, 2016 and June 23 2016. The case consultations in the record failed to identify the members of the treatment team. There was only one documented participant.
Client #10 was admitted on February 11, 2016 and was discharged on August 12, 2016. There was no documented follow up.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
On December 4, 2016, the ABT clinical Director performed a two hour in-service training on the clinical record at the Hazleton site for the Hazleton unit staff.
Included in the training was the DDAP regulation and ABT clinical policy for a "Follow-up." Per ABT clinical policy, the Follow-up is to occur within 30 days of clienmt discharge and includes survey questions regarding ongoing alcohol/other drug abstinence and current needs. Beginning 12/4/16, the Hazleton staff began contacting all ABT treatment completions from November 1, 2016 and forward.
The ABT clinical director will monitor compliance to the Follow UP policy by auditing all client completions that are beyond thirty days.
Also included in the in service training was the facilitation and documentation of a case consultation. The ABT clinical director will monitor compliance by auditing all client open client records on a quarterly basis.
|