INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 9, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Clinical Outcomes Group Incorporated 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 at least 4 hours of TB/STD and other health related topics within the regulatory timeframe in one of two applicable personnel records.Employee #6 was hired as support staff on August 28, 2018 and promoted to a counselor on May 1, 2022. The TB/STD trainings was due to be completed no later than August 28, 2020. The TB/STD training was not completed at the time of the inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #6, will meet with his supervisor and schedule and complete the TB/STD training by March 30, 2023. Executive Director will follow up with Clinical Supervisor by March 30, 2023, to ensure completion. Moving forward the Clinical Supervisor will review all required trainings with new hires during orientation. She will schedule all required trainings for the clinical staff within their first year of employment. |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom disclosure is made on consent to release information forms in seven of seven client records reviewed. Each client record included a release of information form to the "Single County Authority"; however, every release form to the " Single County Authority " in every record did not include the specific name of the person, agency, or organization to whom disclosure would be made.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The release of information for the Single County Authority will now include the following information: Single County Authority - Schuylkill. This will be effective by February 10, 2023. Executive Director and Clinical Supervisor will meet with staff in supervision and staff meeting to review protocol when completing the release of information. Chart audits will occur monthly to ensure compliance. |
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 client records, the facility failed to document, on release of information forms, the date, event, or condition upon which the consent form will expire in three of seven client records reviewed. Client # 1 was admitted on May 31, 2022 and was still active at the time of the inspection. The release of information forms to a funding source, a government agency, a laboratory, a single county authority, and a probation officer were all signed and dated by the client on May 31, 2022; however, none of the release forms included the date, event, or condition upon which the consent would expire.Client # 2 was admitted on June 20, 2022 and was still active at the time of the inspection. The release of information forms to a funding source, a government agency and a single county authority were all signed and dated by the client on June 20, 2022; however, none of the release forms included the date, event, or condition upon which the consent would expire.Client # 6 was admitted on May 13, 2022 and was discharged on July 7, 2022. The release of information forms to a government agency, a laboratory and a single county authority were all signed and dated by the client on May 13, 2022; however, none of the release forms included the date, event, or condition upon which the consent would expire.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #1 will have the release of information forms updated to ensure that the forms are completed correctly by 2/28/23. The clinical supervisor will review the releases to make sure there is an expiration date on all forms. Clinical supervisor will educate all staff during supervision on form completion and will audit charts monthly.
Client # 2 will have the release of information forms updated to ensure that the forms are completed correctly by 2/28/23. The clinical supervisor will review the releases to make sure there is an expiration date on all forms. Clinical supervisor will educate all staff during supervision on form completion and will audit charts monthly.
During group supervision on March 1, 2023, clinical supervisor will educate all staff on the correct way to fill out release of information forms. This will be monitored monthly.
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