INITIAL COMMENTS
|
This report is a result of an on-site licensure inspection conducted on September 20 - 21, 2012 by staff from the Division of Drug and Alcohol Program Licensure.
Based on the findings of the on-site inspection, Cora Services, 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
|
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
|
Observations
Based on the facility's hours of operation, copies of staff CPR and First Aid cards, and a list of employee work schedules, the facility failed to ensure that CPR and First Aid certification was provided to a sufficient number of staff persons, so that at least one person trained in these skills was onsite during the project's hours of operation.
The findings include:
Facility Hours of operation are:
Monday through Thursday 8 AM - 9 PM
Friday 8 AM - 5 PM
On September 20, 2012, copies of staff CPR and First Aid cards were reviewed. The facility did not have a sufficient number of staff persons trained in CPR and First Aid during the project's hours of operation.
There was no one certified in CPR on site during the project's hours of operation on Monday through Thursday from 8 AM to 9 AM.
There was no one certified in CPR on site during the project's hours of operation on Monday through Thursday from 6 PM to 9 PM.
There was no one certified in CPR on site during the project's hours of operation on Friday from 12 PM to 5 PM.
There was no one certified in First Aid on site during the project's hours of operation on Monday's from 8 AM to 8:30 AM, Wednesday's from 8 AM to 9 AM.
There was no one certified in First Aid on site during the project's hours of operation on Monday's from 7 PM to 9 PM and Tuesday from 6 PM to 9 PM.
Employee # 2 is a full-time clinical supervisor.
Employee # 2 works Monday through Thursday from 9 AM to 6 PM and Friday from 8 AM to 12 PM. A review of employee # 1's CPR certification revealed that CPR certification that was issued on 4/19/10 expired 4/2012.
Employee # 4 is a full-time clinical coordinator.
Employee # 4 works Monday from 10 AM to 7 PM, Tuesday from 10 AM to 6 PM, Wednesday from 1 PM to 9 PM, Thursday from 8 AM to 5 PM, and Friday from 9 AM to 3 PM. A review of employee # 4's CPR certification revealed that CPR certification that was issued on 4/19/10 expired 4/2012.
Employee #5 is a full-time counselor.
Employee # 5 works Monday from 8:30 AM to 5:30 PM, Tuesday from 8 AM to 5 PM, Wednesday from 9 AM to 7 PM, Thursday from 12 PM to 9 PM, and Friday from 9 AM to 12 PM. A review of employee # 5's CPR certification revealed that CPR certification that was issued on 4/19/10 expired 4/2012.
Employee # 8 is a full-time counselor.
Employee # 8 works Monday through Thursday from 9 AM to 6 PM, and Friday from 1 PM to 5 PM. A review of employee # 8's CPR certification revealed that CPR certification that was issued on 4/19/10 expired 4/2012.
Employee # 7 is a full-time case manager.
Employee # 7 works Monday through Thursday from 9 AM to 6 PM and Friday from 8 AM to 12 PM. A review of employee # 7's certification revealed that he was the only staff person with current CPR and First Aid certification. CPR and First Aid certification was issued on 1/21/11 and is due for renewal 1/2013.
The Project Director confirmed that staff person's CPR certification had expired.
|
Plan of Correction
All SU Service staff will be trained in CPR and First Aid procedures so that such coverage may be provided during all Ageny hours of SU service operation. As other departments within the Agency have similar coverage requirements, the Agency will schedule necessary CPR/FA trainings on a semi-annual basis in the Spring and Fall of each service year beginning in October, 2012. Staff will then have increased opportunities to remain current with necessary certifications. The next scheduled and comfirmed CPR/FA Certification training for CSD staff is 10/30/2012. CPR/FA certified staff from other Departments within the Agency are presnet during all SU service operating hours and provide necessary coverage in the interim and as a backup going forward. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
|
Observations
Based on a review of personnel records, the facility failed to document fire extinguisher training in one of one record reviewed.
The findings include:
On September 21, 2012, one personnel record requiring documentation of fire extinguisher training was reviewed. The facility did not document fire extinguisher training in one of one personnel record, specifically personnel # 6.
Personnel # 6 is an intern that started training at the program on 8/20/12.
Fire extinguisher training is due upon staff employment.
However, at the time of review, on 9/21/12 the facility failed to document fire extinguisher training for personnel #6.
The Clinical Supervisor confirmed the findings.
|
Plan of Correction
Intern orientation/training procedures have been amended by the CSD Director to include all of the training requirements attributed to new regular staff. In this instance that includes the documentation of fire extinguisher training which was completed for the intern in question on 9/26/2012. New Regular Staff includes all persons who become employees of CORA Services' Community Services Division and will receive this specific fire extinguisher training upon hire as stated in the Standard 705.28.(c)(4). The Clinical Supervisor insures compliance with all training requirements. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
|
Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies in one of one record reviewed.
The findings include:
On September 21, 2012, one personnel record requiring documentation that all personnel on all shifts are trained to perform assigned tasks during emergencies was reviewed.
The facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks, specifically personnel # 6.
Personnel # 6 is an intern that started training at the program on 8/20/12.
At the time of review, on 9/21/12 the facility failed to ensure that personnel # 6 was trained to perform assigned tasks during emergencies
The Clinical Supervisor confirmed the findings.
|
Plan of Correction
Intern orientation/training procedures have been amended by the CSD Director to include all of the training requirements attributed to new regular staff. In this instance that includes the documentation of emergency procedures training which was completed for the intern in question on 9/26/2012. New Regular Staff includes all persons who become employees of CORA Services' Community Services Division and receive this specific Emergency Procedures training upon hire. The Clinical Supervisor ensures compliance with all training requirements. |
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. The consent shall be in writing and include, but not be limited to:
|
Observations
Based on a review of client records and clinical documentation, the facility failed to document an informed and voluntary consent for the disclosure of information in thirteen out of thirteen client records.
The findings include:
Thirteen client records were reviewed on September 20 - 21, 2012. The facility failed to document an informed and voluntary consent from the client in thirteen out of thirteen client records reviewed, # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, and 13.
In all client records reviewed, # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, and 13; the client's signed the "Cora Services, Inc. Pennsylvania Notice Form" or the facility's HIPPA form which failed to comply with 42 CFR and 4 Pa. Code 255.5.
The "Cora Services, Inc. Pennsylvania Notice Form" or the facility's HIPPA form did not contain documentation of the client's right to verbally revoke a signed consent. The facility documented "You may revoke all such authorizations of PHI or psychotherapy notes at any time, provided each revocation is in writing."
This does not comply with 42 CFR Subpart C, Subsection 2.31 (c) (3) which stipulates that a disclosure may not be made on the basis of a consent which is known to have been revoked.
In addition, the "Cora Services, Inc. Pennsylvania Notice Form" or the facility's HIPPA form documented under the section "Worker's Compensation - If you file a worker's compensation claim, CORA will be required to file periodic reports with your employer which shall include: pertinent, history, diagnosis, treatment, and prognosis."
4 Pa. Code 255.5 (a)(6) states: Projects may disclose with clients consent, in writing, the information to employers of a client to further the client's rehabilitation....Such information shall be limited to whether the client has or is receiving treatment with the project.
The Clinical Coordinator did not dispute the findings.
|
Plan of Correction
CORA's PA Notice Form, also known as the facility's HIPPA form has been amended to include documentation of the client's right to revoke consent for disclosure both verbally and in writing and the revocation date for either option has been added to the form.
Additionally, the Worker's Compensation clause in the same form has been amended to limit disclosure of client information with the client's written permission to whether the client has or is receiving services within the project.
Staff are being retrained on this process by the Clinical Supervisor and current clients will be offered the opportunity for a review and resigning of the corrected form and will be offered copies of same. This process will be completed by 11/1/2012. |