Observations
Based on the review of personnel records, the facility failed to document that staff persons received a minimum of 6 hours of HIV/AIDS and/or at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum as required, in two of three personnel records.
The findings include:
Seven personnel records were reviewed on July 27, 2015. Three personnel records were reviewed for compliance with the required training. The facility failed to provide documentation of the required training in personnel records # 6 and 7.
Employee #6 was hired as a treatment aid on April 27, 2011. The minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics were to be completed by April 27, 2013. There was no documentation as of July 27, 2015 that the training had been completed.
Employee #7 was hired as a treatment aid on October 8, 2010. At least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training was to be completed by October 8, 2012. There was no documentation as of July 27, 2015 that the training had been completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All Renewal Treatment, Inc. staff 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, as required. Employee #6 and Employee #7 have been counseled by their supervisor titled the TA Shift Supervisor as well as the Clinical Supervisor. These two employees are being scheduled for the next available training that utilizes the Department approved curriculum. The TA Shift Supervisor and the Clinical Supervisor shall ensure that all staff attend their required training and shall receive proof of attendance (training certificate) which will be placed in their training file. Additionally, the TA Shift Supervisor shall complete training needs assessments on all new hires within their first 30 days of employment ensuring that each new employee are aware of their training needs. These training needs assessments shall be completed annually in each subsequent year of employment. Employee #6 and #7 shall have attended the required trainings within 30 days with documentation placed in their training file. The Clinical Supervisor shall regularly review training requirements with all clinical staff during regular supervision sessions and during the completion of the annual training needs assessments. The Clinical Supervisor shall ensure that all clinical staff are scheduled for all required trainings during those reviews. This plan of correction is in place and ongoing with oversight by the TA Shift Supervisor and Clinical Supervisor. |
Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client that included the name of the person, agency or organization to whom disclosure is made, specific information to be released and purpose of disclosure in five of thirteen client records.
The findings include:
Eleven client records were reviewed on July 27-28, 2015. All eleven client records were required to include an informed and voluntary consent from the client. A consent to release information was not obtained in records # 1, 2, 5, 7 and 11.
Client # 1 was admitted on June 9, 2015. A release for a government agency, signed by the client on June 9, 2015, did not include the specific information to be released. A release for pretrial services, signed by the client on June 9, 2015, did not include the specific information to be released. A release for a treatment provider, signed by the client on June 9, 2015, did not include the specific information to be released. There were two separate releases for two separate funding sources, signed by the client on June 9, 2015, that did not include the specific information to be released or the purpose of disclosure. A release, signed by the client on June 9, 2015 did not include the the name of the person, agency or organization to whom disclosure is made, specific information to be released or the purpose of disclosure.
Client # 2 was admitted on May 26, 2015. A release, signed by the client on May 26, 2015, did not include the the name of the person, agency or organization to whom disclosure is made or the purpose of disclosure
Client # 5 was admitted on July 6, 2015. A release for an appointment, signed by the client on July 22, 2015, did not include the purpose of disclosure. A release for a treatment provider, signed by the client on July 16, 2015, did not include the purpose of disclosure. A release to a person, signed by the client on July 9, 2015 did not include the purpose of disclosure.
Client # 7 was admitted on June 8, 2015. A release to a person, signed by the client on July 16, 2015, did not include the purpose of disclosure.
Client # 11 was admitted on April 13, 2015 and discharged on June 15, 2015. A release for a treatment provider, signed by the client on June 12, 2015, did not include the specific information to be released or the purpose of disclosure.
These findings were reviewed with facility during the licensing process.
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Plan of Correction
Renewal Treatment, Inc. clinical staff shall obtain an informed and voluntary consent from the client that includes the names of the person, agency or organization to whom the disclosure is made, specific information to be released and purpose of disclosure. The Clinical Supervisor shall ensure that the clinical staff correct the releases cited in observation #0277 in an immediate fashion. The Clinical Supervisor shall provide additional training on informed and voluntary consent requirements immediately. All consents shall be corrected immediately by the clinical staff. The Clinical Supervisor shall provide follow-up ensuring compliance with this requirement during weekly supervision and regular chart reviews. The overall oversight of this plan of correction shall be the responsibility of the Clinical Supervisor and Clinical Director. This plan of correction is in place and ongoing. |