INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 9, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Children's Service Center of Wyoming Valley, 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 on June 9, 2016, the facility failed to ensure that Employee #4 completed 4 hours of STD/TB training as required within one year of employment.
Employee # 4 was hired as a counselor on February 9, 2015 and did not complete the required training at the time of the licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counselor is registered to attend a training on TB/STD's 7/14/16, 4 hours at Just Believe Recovery Carbondale, PA. Facility Director will monitor completion of this training for 7/14/16 When a new employee is hired, a reminder will be put into our electronic training system (Relias)for TB/STD training to be within the year of employment. Facility Director will monitor all new employees for completion on TB/STD training thorough electronic Relias training
System. .
Counselor attempted several times to register for this DDAP training without success due to no availability of seats during the first year of employed in the Program.
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705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of the fire drill record on June 9, 2016, the facility failed to conduct fire drills at different times of the day and on different staffing shifts.
The facility hours are from 8:00 am to 8:00 pm Monday through Thursday and 8:00 am to 5:00 pm on Friday. All fire drills were conducted between 8:01 am until 9:16 am for the twelve month period.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Fire drills will be conducted monthly on different days of the week, different times and different staffing shifts beginning June 28.
The Facility Director will coordinate the fire drills with the Safety Staff Employee within the building, monthly. Fire drills will be reviewed with the Compliance Officer and the Facility Director monthly.
Fire drills in the past were held at 8-9 am due to high volume of clients during the day which would impact patient care. Many of the clients are autistic children in our Outpatient Department within this building.
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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.
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Observations
Based on the review of client records on June 9, 2016, the facility failed to provide a required disclosure of information consent in six of six client records reviewed.
Client #1 was admitted to treatment on December 15, 2015 and is still an active client. There was no consent to release information to a funding source although the facility verified that information was released to this agency for billing purposes.
Client #2 was admitted to treatment on April 27, 20165 and is still an active client.
There was no consent to release information to a funding source although the facility verified that information was released to this agency for billing purposes.
Client #3 was admitted to treatment on July 15, 2015 and discharged March 9, 2016. There was no consent to release information to a funding source although the facility verified that information was released to this agency for billing purposes.
Client #4 was admitted to treatment on June 23, 2015 and discharged November 3, 2015. There was no consent to release information to a funding source although the facility verified that information was released to this agency for billing purposes.
Client #5 was admitted to treatment January 22, 2015 and discharged November 20, 2015. There was no consent to release information to a funding source although the facility verified that information was released to this agency for billing purposes.
Client #6 was admitted to treatment on February 10, 2015 and discharged September 22, 2015. There was no consent to release information to a funding source although the facility verified that information was released to this agency for billing purposes.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An inservice was provided with the Counselors on 6/28 to emphasis compliance with releases. Counselors will complete releases on active clients during the next scheduled session and new clients upon first assessment session. Facility Director will review all active clients for releases as clients are scheduled for their appointments. Facility Director will review all new clients charts for release to the funding source for the next quarter for compliance.
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709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to provide services according to the individual treatment and rehabilitation plan in three of six client records reviewed.
Client #1's individual treatment and rehabilitation plan was developed on February 2, 2016 and stated the client was to be seen one time per week for individual sessions. Client was not seen during the weeks of 2/29/16, 3/14/16, 3/21/16. 3/28/16, 4/25/16, 5/9/16 or 5/31/16.
Client #3's individual treatment and rehabilitation plan was developed on August 6, 2015 and stated the client was to be seen one time per week for individual sessions. Client was not seen during the weeks of 8/10/15, 8/24/15, 9/28/15, 10/5/15, 10/12/15, 10/26/15, 11/9/15, and did not have an individual sesstion the month of December 2015.
Client #5''s individual treatment and rehabilitation plan was developed on February 19, 2016 and stated the client was to be seen one time per week for individual sessions. Client was not seen during the weeks of 2/23/15, 4/13/15, 4/20/15, 4/27/15, 6/1/15, 6/8/15, 6/22/15, 6/29/15 and did not have an individual session for the months of March, July, and August of 2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An inservice was held with the staff by the Facility Director on 6/28.
The Counselor will document in the record of service the reason why a counseling session was not held in accordance to the treatment plan as of 6/28.
Active Clients chart have been documented to reflect why a client was not seen for scheduled session as of 6/28. If client fails an appointment, the Counselor will make a telephone contact with the client to attempt to re engage the client in counseling and document the date of follow up in the record of service.
The Facility Director will complete random quality reviews of the cases monthly to assure proper documentation of care is noted.
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