INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on May 23, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Peace Valley Recovery LLC, 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)(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 a review of personnel files and the facility ' s Staffing Requirement Facility Summary Report, the facility failed to ensure all staff persons received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health topics training within the regulatory time frame in two of two applicable personnel records reviewed.
Employee #4 was hired as a counselor on September 30, 2020. The HIV/AIDS training was due no later than September 30, 2021. However, the training was not completed as of the date of the inspection.
Employee# 6 was hired as a Behavioral Health Technician on November 1, 2019. The HIV/AIDS and TB/STD trainings were due no later than November 1, 2021. However, the trainings were not completed as of the date of the inspection.
The findings were discussed with facility staff during the licensing process
|
Plan of Correction
PVR had employee #4 sign up and enroll for Basic HIV Parts 1 and 2 through DDAP and it is scheduled for 6/22/22 and 6/23/22. Employee #4 was also able to sign up and enroll for TB/STD/Hepatitis training through DDAP and it is scheduled for 7/13/22.
PVR had employee #6 sign up and enroll for Basic HIV Parts 1 and 2 through DDAP and it is scheduled for 6/22/22 and 6/23/22. Employee #6 was also able to sign up and enroll for TB/STD/Hepatitis training through DDAP and it is scheduled for 7/13/22.
Facility director will ensure that all employees have their HIV/AIDS and TB/STD/Hepatitis trainings completed within their first year of employment with PVR. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
|
Observations
Based on a review of personnel files, the facility failed to ensure that annual written individual performance evaluations, which shall be reviewed and signed by the employee, were completed in one of one applicable personnel record reviewed.
Employee #4 was hired as a counselor on September 30, 2020. There was no documentation that the annual written individual performance evaluation was completed for prior year reviewed.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Facility director will ensure that all employees have their annual written individual performance evaluations, which shall be reviewed and signed by the employee, completed on time and kept in the employee's personnel file. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
|
Observations
Based on a review of client records, the facility failed to keep consent forms for the disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (a) for releases of information in fourteen of fourteen client records reviewed.
Each client record reviewed had a release of information form to the funding source that allowed for the release of treatment plans, legal status, psychiatric history and assessment, psychological assessment, results of physical exam, medical history/current status, biopsychosocial assessment, laboratory test results, employment information, family information, aftercare recommendations, discharge planning and discharge summary, all of which exceeded the limits established by 4 Pa. Code 255.5.
This is a repeat citation from the June 16, 2021 licensing inspection.
This finding was reviewed with facility staff during the licensing process
|
Plan of Correction
PVR created consents to the funding source for each client. Each consent is completed upon client's initial intake. Facility Director created the consents in the EHR on 05/31/2022. Facility Director and Clinical Director will ensure that the consents are being completed during regular chart checks. All active clients had new consents completed in their charts as of current, 6/8/2022. |