INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 17, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Renewal Treatment, 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:
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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 on October 15, 2019 at the corporate office and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee #4 received at least four hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #4 was hired as a counselor on September 25, 2017 and was due to have the communicable disease trainings no later than September 25, 2018. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All Renewal Treatment staff shall complete TB/STD and health related training topics within the regulatory time frames. The Clinical Supervisors and Counselor staff received instruction; provided by the Clinical Director, on this deficiency and the requirements for completing training within required time frames. All Counselor staff shall review their training requirements annually with the Clinical Supervisor during performance appraisal and during the completion of their training needs assessments. Clinical Supervisors shall ensure that all required training including TB/STD and other health related topics is registered for/scheduled for all staff needing this training and shall be registered/scheduled and completed within regulatory time frames. Documentation of completed training shall be placed in each Counselor's training file. Renewal, Inc.'s Director of Human Resources and Compliance, or designee shall internally audit all counseling staff's training records bi-annually and provide training completion updates to the Clinical Supervisors and Clinical Director. These bi-annual audits will ensure that Counseling staff are meeting their training requirements. The Project Director, Clinical Director and Clinical Supervisors shall have overall oversight of this plan of correction. This plan of correction is in place. |
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 the review of client records on October 17, 2019, the facility failed to document completed consent to release information forms in client #7's record, a consent to release form was missing to whom disclosure is to be made.
Client #7 was admitted on March 4, 2019 and discharged on June 10, 2019. The consent to release information form with the missing disclosure information was signed by client on March 4, 2019.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Renewal Treatment, Inc. shall complete consent to release information forms for all whom disclosure of information is to be made. Renewal Treatment Inc.'s Counselor staff shall ensure that consent to treatment forms are completed in their entirety and identify all whom disclosure is to be made. The consent to release information forms shall be signed by the client and maintained in each client's case record. The Clinical Supervisor staff provided instruction and training to the Counselor staff on this deficiency and requirement. The Clinical Supervisor staff shall ensure continual compliance via regular, documented file audits. This plan of correction is in place. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records on October 17, 2019, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5(b) for releases of information in client record #2.
Client #2 was admitted on October 11, 2018 and was discharged on April 15, 2019. A consent to release form was signed and dated on October 11, 2018 to the funding source that allowed for the release of "other" information.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Renewal Treatment, Inc. shall keep disclosures of client identifying information within the regulatory limits. Renewal, Treatment, Inc. has removed the "other" from the funding source's disclosure form and shall notify the funding source that this form is out of regulatory compliance. Renewal Treatment, Inc. Counselor staff has received instruction/training in regards to this deficiency and the requirements to keep information disclosures within regulatory requirements. Renewal Treatment, Inc.'s counselor staff has begun the process and shall ensure all current clients sign the revised consent to release form which shall be documented in each client's record. The Clinical Supervisor shall perform regular file audits ensuring compliance with this plan of correction. The Clinical Director and Clinical Supervisor shall have overall oversight responsibilities for this plan of correction. This plan of correction is in place. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of the facility's policy and procedure manual on October 15, 2019 at the corporate office, the facility failed to include documentation of all the required client rights, including that the facility will not discriminate based on marital status. In addition, in a review of seven client records on October 17, 2019, the facility failed to ensure that the client was made aware of all of their rights in client records #1, 2, 3, 4, 5, 6 and 7. The signed acknowledged client rights did not include that the facility will not discriminate based on marital status.
Client #1 was admitted on June 11, 2019 and was still active at the time of the inspection.
Client #2 was admitted on October 11, 2018 and was discharged on April 15, 2019.
Client #3 was admitted on January 25, 2019 and was discharged on June 24, 2019.
Client #4 was admitted on December 20, 2018 and was discharged on May 9, 2019.
Client #5 was admitted on May 28, 2019 and was still active at the time of the inspection.
Client #6 was admitted on April 26, 2019 and discharged on July 13, 2019.
Client #7 was admitted on March 4, 2019 and discharged on June 10, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Renewal Treatment, Inc.'s client bill of rights shall document all required client rights, including that the facility will not discriminate based on marital status. All Renewal Treatment, Inc. clients shall be made aware of these rights by signing an acknowledgment that will be maintained in their case record. Renewal Treatment, Inc. has revised it's Client Bill of Rights to include marital status which is included within the body of the Client Consent to Treatment. All Counselor staff have received instruction on this deficiency and the changes that were made to the Client Bill of Rights and Client Consent to Treatment form. Counselor staff shall have all current and future clients sign the new revised Client Consent to Treatment/Client Bill of Rights and place this documentation in the client file. The Clinical Supervisors shall ensure compliance by performing regular internal client file auditing. The Clinical Director and Clinical Supervisors shall have overall oversight responsibilities for this plan of correction. This plan of correction is in place. |
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 seven client records on October 17, 2019, the facility failed to document treatment plan updates within the regulatory timeframe in three client records reviewed.
Client #1 was admitted on June 11, 2019 and was still active at the time of the inspection. A treatment plan was completed on June 24, 2019 and an update was due no later than August 24, 2019; however, the update was completed on September 17, 2019.
Client #2 was admitted on October 11, 2018 and discharged on April 15, 2019. A treatment plan was completed on October 26, 2018 and an update was due no later than December 26, 2018; however, an update was completed on February 4, 2019.
Client #4 was admitted on December 20, 2018 and discharged on May 9, 2019. A treatment plan was completed on January 8, 2019 and an update was due no later than March 8, 2019; however, an update was completed on April 2, 2019.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Renewal Treatment, Inc. staff shall perform treatment plan updates within the regulatory time frames. Renewal Treatment, Inc. staff shall perform treatment plan updates at least every 60 days while the client is in the program. These treatment plan updates shall be documented and placed in each client's case record. The Clinical Supervisors have provided training/instruction for the Counselor staff on this deficiency/regulatory requirement. The Clinical Supervisors shall ensure compliance with this requirement via supervision and regular internal client record auditing. The Clinical Director and Clinical Supervisors shall have overall oversight responsibilities for this plan of correction. This plan of correction is in place. |