INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 4, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, PA Treatment and Healing 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 personnel records and the facility's Staffing Requirement Facility Summary Report form, the facility failed to ensure that employees received the minimum of six hours of HIV/AIDS training within the regulatory timeframe.
Employee #4 was hired as a counselor on May 10, 2021 and was due to have the communicable disease trainings no later than May 10, 2022. There was no documentation in the personnel file of the completion of the HIV/AIDS training as of the date of the inspection.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
the facility failed to ensure that employees received the minimum of six hours of HIV/AIDS training within the regulatory timeframe.
Employee #4 was hired as a counselor on May 10, 2021 and was due to have the communicable disease trainings no later than May 10, 2022. There was no documentation in the personnel file of the completion of the HIV/AIDS training as of the date of the inspection.
The facility director has met with the staff member and has instructed the counselor to schedule for the next available DDAP HIV/AIDS training to ensure that all obligations of training requirements are met.
The agency will be in compliance with this standard as of 12/31/2022 |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a review of administrative documents and an interview with theProject Director, the project failed to document an annual financial audit for the fiscal year ending June 30, 2021.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
the project failed to document an annual financial audit for the fiscal year ending June 30, 2021.
The facility director has taken this citation to the financial director and President to address as needed. I have been informed that a plan of correction has been submitted on the corporate level for this situation and the agency is in the process of having a financial audit completed.
The agency will be in compliance with this standard as of 12/31/22 |
709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of the client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the clients that recorded the date, event, or condition upon which the consent will expire in one out of seven records reviewed.
Client #6 was admitted on March 16, 2022 and discharged on May 31, 2022. A release of information dated March 16, 2022 was to a medical provider.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the clients that recorded the date, event, or condition upon which the consent will expire in one out of seven records reviewed.
Client #6 was admitted on March 16, 2022 and discharged on May 31, 2022. A release of information dated March 16, 2022 was to a medical provider.
The facility director will meet with all counselors to review the policies and procedures for correctly completing all aspects of an appropriate consent.
The facility director and Lead Counselor will monitor compliance with these standards through continued supervision and quality review of client files
The agency will be in compliance with this standard as of 10/30/2022 |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of the client records, the facility failed to document that a copy of a client consent shall be offered to the client and a copy maintained in the client record in one out of seven client records reviewed.
Client #6 was admitted on March 16, 2022 and discharged on May 31, 2022. A release of information dated March 16, 2022 was to a family member.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
the facility failed to document that a copy of a client consent shall be offered to the client and a copy maintained in the client record in one out of seven client records reviewed.
Client #6 was admitted on March 16, 2022 and discharged on May 31, 2022. A release of information dated March 16, 2022 was to a family member.
The facility director will review with all counselors the proper and complete way to document that the client has received or declined a copy of the consent that is kept in the client file.
The facility director and lead counselor will monitor compliance with these standards through continued supervision and quality review of client files.
The agency will be in compliance with this standard as of 10/30/2022 |