INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 26, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Community Counseling Center of Mercer County 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
The facility failed to provide documentation of TB/STD training in two of four personnel/training records.
Staff #3 was hired 5-16-2016 and required to complete TB/STD training by 5-16-2017. As of the date of the inspection, the training was not completed.
Staff #4 was promoted to counselor position on 11-18-2015 and required to complete TB/STD training by 11-18-2016. As of the date of the inspection, the training was not completed.
These findings were reviewed with the facility staff.
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Plan of Correction
No training was offered within the time frame that was accessible and affordable. These two staff have been registered and scheduled to attend the next accessible training through our local SCA. This training is scheduled for March 15,2018.
It is the responsibility of the Facility Director to assure that the staff attend the training and that the documentation is placed in the personnel chart by March 31,2018.
In the future, the budget will be developed to access funds to assure that new hires receive training within the regulatory time frame. |
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
The facility failed to obtain an informed and voluntary consent from the client prior to disclosure in one of seven client records reviewed on January 26, 2018.
Client #7 was admitted to treatment on October 17, 2017. The facility failed to document a release of information prior to disclosure of information. A letter was faxed to another treatment provider on 11-17-2017, and release of information to that treatment provider was not signed until 1-2-2018.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
While this was an oversight on the part of this therapist, a review of the importance of assuring that a consent is completed before the release of information.To this end, an in service will be provided to all clinicians which will review the importance of confidentiality, the rules for release of information and the correct completion of consents. This in service will be provided by the facility director and Compliance Director by June 1, 2018.
The individual directly cited will receive a review during supervision and the facility director will provide on going monitoring weekly to assure compliance. Compliance will be achieved by February 12,2018.
Ongoing, every effort will be made to regularly send staff to refresher training when they are offered.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
The facility failed to document a treatment plan update in two of six client records reviewed during the annual licensing inspection.
Client #4 was admitted to treatment on July 14, 2017, and was discharged on October 10, 2017. The comprehensive treatment plan was completed on July 25, 2017. A treatment plan update was due by September 25, 2017, and was not documented.
Client #6 was admitted to treatment on November 3, 2017. The comprehensive treatment plan was completed on November 9, 2017. A treatment plan update was due by January 9, 2018, and was not documented as of the date of the annual inspection.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Both of these charts were the responsibility of the same clinician. The Facility Director will meet with this clinician and develop a personal plan of correction to prevent this from happening in the future. The team meeting will be used to review the regulation and the need to complete the update regardless of the client's attendance. Both will be completed by February 28, 2018. Compliance will be monitored by the Facility Director and Compliance Director Quarterly. |
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:
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Observations
The facility failed to document an aftercare plan in one of three client records reviewed during the annual licensing inspection.
Client record #4, the client was admitted on July 14, 2017 and was successfully discharged on October 10, 2017. There was no documentation of an aftercare plan.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The weekly treatment team meeting will be used to review the purpose of the Aftercare Plan and the role it plays in the ongoing management of a client's recovery. This will be reviewed and practiced in team meeting by March 31, 2018. Compliance will be monitored in quarterly audits by Facility Director and the Compliance Director. |