INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on October 20, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Persad Center Inc. 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee #5 received the minimum of at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.Employee #5 was hired as a counselor on May 4, 2020 and was due to have the communicable disease trainings no later than May 4, 2021. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.This is a repeat violation from February 23, 2021 annual licensing inspection.The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Clinical Supervisor will make sure that trainings are, at least, scheduled within the first 6 months of employment. If trainings are unable to be scheduled within the first 6 months of employment the Clinical Supervisor will contact DDAP to apply for an extension/exception. The Clinical Supervisor has created a spreadsheet to keep track of training need(s). |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
|
Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation. At the time of inspection, there was only one clerical staff member who held a valid CPR certification. The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
At the time of this visit we the Clinical Director had already scheduled CPR/First aid training for 11/12/21. The Clinical Supervisor will ensure that follow up training occurs at least 6 months prior to the date of expiration of the CPR/First Aid certification. |
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).
|
Observations
Based on the review of client records, the facility failed to 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 limited to a dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) in six out of seven records reviewed for the funding source. The facility confirmed that the funding services were billed for services. Client #1 was admitted on April 30, 2021 and was an active client at the time of the inspection. Client #2 was admitted on May 28, 2021 and was an active client at the time of the inspection. Client #3 was admitted on March 15, 2021 and was an active client at the time of the inspection. Client # 4 was admitted on January 28. 2021 and was discharged on June 4, 2021. Client#5 was admitted on April 22, 2021 and was an active client at the inspection. Client#7 was admitted on June 25, 2021 and discharged on July 21, 2021. The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
As of 11/01/2021, the clinical supervisor made the following protocol: any individual that identifies current substance use/use within the last 6 months will be required to have an in-person intake/assessment to ensure that all consents are signed on the day of the appointment. |
709.28 (c) (5) 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:
(5) Dated signature of witness.
|
Observations
Based on the review of client records, the facility failed to 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 limited to a dated witness signature for one out of seven client records reviewed for the funding source. The facility confirmed that the funding source was billed for services. Client #6 was admitted on May 21, 2020 and was discharged on March 6, 2021. The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
As of 2/1/2021 Persad uses an EHR and all consents are completed out of the EHR. The witness signature is required and so the form cannot be completed without completing this field. The error found in this area was part of the client's paper chart. |
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.
|
Observations
Based on the review of client records, the facility failed to document that a copy of a client consent shall be offered to the clients and copy maintained in the client record in one out of seven records reviewed. Client #6 was admitted on May 21, 2020 and was discharged on March 6, 2021. The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
All consent forms are completed out of out EHR. The consent to release information has required fields and acceptance/decline of a copy is one of the required fields so it cannot be missed. We have had our EHR since 2/1/2021, the errors found were part of the client's paper chart. |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
|
Observations
Based on a review of client records, the facility failed to ensure that an individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of proposed type of support services in seven out of seven records reviewed. The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
On 10/20/2021, the clinical supervisor added "proposed type of support services" was added to our treatment plan. The auditor was shown this while here on site. |
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.
|
Observations
Based on a review of client records, the facility failed to ensure that treatment and rehabilitation plans shall be reviewed and updated at least every 60 days on four out of seven records reviewed. Client #1 was admitted on April 30, 2021 and was an active client at the time of the inspection. A comprehensive treatment plan was developed on June 3, 2021 and the next update was due no later than August 3, 2021, however an update was not completed until September 20, 2021. Client # 4 was admitted on January 28, 2021 and was discharged on June 4, 2021. A comprehensive treatment plan was developed on March 23, 2021 and the next update was due no later than May 24, 2021, however there was no update at the time of the inspection.Client # 5 was admitted on April 22, 2021 and was an active client at the time of the inspection. A comprehensive treatment plan was developed on June 22, 2021 and the next update was due no later than August 21, 2021, however an update was completed until September 7, 2021. Client #6 was admitted on May 21, 2020 and was discharged on March 6, 2021. A comprehensive treatment plan was developed on May 21, 2020 and the next update was due no later than July 20, 2020, however an updated was completed until October 20, 2020. The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
On 10/20/2021 an email was circulated to DnA therapist's to complete treatment plans with or without the client present every 60 days (we had been having therapists wait for the client to be present). Also, our EHR sends reminders/prompts to the therapist when plans are coming due to ensure that they are completed on time. |
709.93(a)(11) 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:
(11) Follow-up information.
|
Observations
Based on a review of client records, the facility failed to ensure that 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 limited to follow up information on two out of three records reviewed. Client # 4 was admitted on January 28. 2021 and was discharged on June 4, 2021. Client#7 was admitted on June 25, 2021 and discharged on July 21, 2021. The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
On 10/20/2021 the clinical supervisor sent an email reminder to all DnA therapists reminding them of the 30 day follow up. This will be included in our DnA chart audit to ensure that this is not missed. Also, our EHR provides the clinical supervisor with a bi-weekly report of discharged clients. For DnA client's a reminder will be sent to the therapist with the due date for this call/follow-up. |