INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 8, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, New Freedom Recovery Center 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 the review of personnel records, the facility failed to ensure that staff received at least 4 hours of tuberculosis, sexually transmitted diseases, and other health related topics training within the first year of employment, in one of one record.Employee # 3 was hired as a counselor on March 16, 2020. The STD/TB training was to be completed by March 16, 2021. There was no documentation the employee completed the training. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon instructions from the Project Director Employee #3 will schedule by year end the STD/TB training. The Compliance Officer will ensure that the training is completed and will ensure that any new hires complete the training within the time frame in compliance with 704.11(c)(1) . |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on the review of personnel records, the facility failed to ensure that the project/facility director completed at least 12 clock hours of training annually, in one of one record.Employee # 1 was hired as the project/facility director on December 10, 2015. There were only 7 hours of training documented for the January to December 2020 training year. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Compliance Officer met with all staff to review training hours needed by each staff member on a yearly basis. The Compliance Officer will monitor training hours completed by each staff member via completed training certificates and training evaluations, to be kept in file for each staff member. The Compliance Officer will assure that all staff comply with 704.11(d) (2) Licensure. |
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, the facility failed to obtain an informed and voluntary consent from the client in seven of seven records. Client records # 1, 2, 3, 4, 5, 6 and 7 had releases for a laboratory for the purpose of submitting urine screens. The specific information to be released did not include urine samples. Urine samples were sent to the laboratory. Client # 1 was admitted on June 24, 2021 and was still an active client at the time of the inspection. A letter was sent to an employer on June 21, 2021 that exceeded 4 Pa Code 255.5. Client # 4 was admitted on October 13, 2020 and discharged on January 18, 2021. A release of information to an attorney did not document the specific information to be released. Letters were sent to the attorney on October 13 and November 12, 2020.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon instructions from the Project Director, the Human Resource Manager has revised our Consent to Release Confidential Information. HRM has destroyed all incorrect Consents. The HRM will be responsible for maintaining the revised Consent to Release Confidential Information and will ensure that all new clients sign and receive the revised consent upon the new admission process in compliance with 709.28 (c) Licensure.
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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.
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Observations
Based on the review of client records, the facility failed to obtain a consent from the client that included the specific information to be disclosed in one of seven client records. Client # 4 was admitted on October 13, 2020 and discharged on January 18, 2021. A release of information to an attorney did not document the specific information to be released. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon instructions from the Project Director, the Human Resource Manager has revised our Consent to Release Confidential Information to an outside source to show the information to be disclosed. The HRM has destroyed all incorrect consents. The HRM has met with the Clerical Staff to review this revision. The HRM will be responsible for maintaining the revised consents and will ensure that all new clients receive and sign the revised consent. |