INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 27, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, WES Corporation 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, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in one of one applicable personnel records reviewed.
Employee # 1 was hired as the project director on November 1, 2019 and was due to have TB/STD training no later than November 1, 2021. The TB/STD training was not completed at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff will be registered and complete the required 6 hours of HIV/AIDS and 4 hours of TB/STD training.
Program Director shall meet with HR staff on a quarterly basis to review training files and confirm that all program staff have completed the required hours for HIV/AIDS and TB/STD training. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility's December 2020 through December 2021 fire drill log, the facility failed to ensure that unannounced fire drills were conducted at least once a month. There were no fire drills completed for the months of June 2021 and August 2021 in the facility's fire drill log.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will review fire drill logs on the 25th day of each month to ensure that fire drills are completed monthly. |
709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
Based on an administrative review, the facility failed to document, and make available to the public, an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders.
This finding was discussed with facility staff during the licensing process.
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Plan of Correction
WES CEO and CFO will complete a current annual report and make this available to the public by 5/7/2022.
The WES Director of Quality Management shall meet with members of the executive team to on a quarterly basis to set deadlines and track progress of completion of the agency Annual Report. |
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 a review of client records, the facility failed to document the specific information to be disclosed on consent to release information forms in two of seven client records reviewed.
Client # 4 was admitted on February 1, 2021 and was discharged on October 13, 2021. The release of information form to the funding source was signed and dated by the witness on February 6, 2021, but the release form allowed for the release of "all pertinent information", which is not specific enough. Additionally, the release of information form to a community agency was signed and dated by the witness on April 24, 2021, but the release form allowed for the release of "all pertinent information " , which is not specific enough.
Client # 6 was admitted on March 11, 2021 and was discharged on July 29, 2021. The release of information form to the funding source was signed and dated by the witness on March 29, 2021, but the release form allowed for the release of "all pertinent information", which is not specific enough.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director will modify release of information forms for program funders to include specific information to be released and obtain signatures from clients for the identified client records.
The Program Director shall review client records on a monthly basis to ensure that client release of information forms identifies specific information that is to be released. When it is found that specific information is not included, the program director shall meet with relevant staff and direct the staff to amend the release of information with the client and secure the signature of the client that provides consent for this. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document the dated signature of the client on release of information forms in seven of seven client records reviewed.
Every release of information form in each client record reviewed failed to document the dated signature of the client.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The program support staff will obtain updated release of information forms from each client that include the client's signature and the date it was signed.
The Program Director shall review client records on a monthly basis to ensure that release of information forms include the signature of the client and the date the client signed the release of information. |
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
Based on a review of client records, the facility failed to review and update treatment and rehabilitation plans at least every sixty days in five of six applicable client records reviewed.
Client # 1 was admitted on March 9, 2021 and was still active at the time of the inspection. A treatment plan update was completed on July 21, 2021 and the next update was due no later than September 21, 2021; however, the update was not completed until October 17, 2021. Additionally, the next update was due no later than December 17, 2021; however, the update was not completed at the time of the inspection.
Client # 2 was admitted on July 22, 2021 and was still active at the time of the inspection. A treatment plan update was completed on October 21, 2021 and the next update was due no later than December 21, 2021; however, the update was not completed at the time of the inspection.
Client # 3 was admitted on August 9, 2021 and was still active at the time of the inspection. The individual treatment plan was completed on October 25, 2021 and an update was due no later than December 25, 2021; however, the update was not completed at the time of the inspection.
Client # 4 was admitted on February 1, 2021 and was discharged on October 13, 2021. A treatment plan update was completed on March 24, 2021 and the next update was due no later than May 24, 2021; however, the update was not completed until August 13, 2021.
Client # 5 was admitted on April 29, 2021 and was discharged on September 24, 2021. The individual treatment plan was completed on June 17, 2021 and an update was due no later than August 17, 2021; however, the update was not completed prior to discharge.
This is a repeat citation from the January 28, 2021 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical staff shall update all client treatment and rehabilitation plans every 60 days, whether client is present or not to review. Clinical staff shall note on the update that client did not attend this review due to a missed appointment.
The program director shall review client records on a monthly basis to ensure that clinical staff are updating treatment and rehabilitation plans every 60 days. When it is found that these are not being updated every 60 days, the program director will develop a performance improvement plan with the clinician to correct this deficiency. |