INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 24, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Cen-Clear, 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, the facility failed to ensure staff received the minimum of at least 4 hours of TB/STD and other health related topics within the first year of employment in one of three applicable records.
Staff #5 was promoted to counselor on January 23, 2023 and still employed at time of inspection. Staff #5 was due to have the communicable disease trainings no later than January 23, 2024. There was no documentation provided of the completion of the TB/STD training as of the date of the inspection.
The findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
In a review of factors contributing to this it was determined that the affected staff had scheduled a TB/STD training within the required timeframe that was then cancelled by the trainer.
Per feedback proffered by our licensing representative during the review, division leadership has developed an internal training using the minimum content requirements outlined in DDAP Licensing Alert 6-97 for delivery to internal staff on a twice/year basis. The first of these trainings is scheduled to occur in November of 2024, and the second in April of 2025. They will continue at that frequency and as-needed to ensure full compliance with all training requirements. Timely completion of training requirements will remain the purview of our Training Coordinator who will continue to generate bi-annual training reports to Clinical Supervisors for review.
Staff #5 completed the training on April 16, 2024. |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document a purpose of disclosure on the release of information form in one of seven records.
Client #7 was admitted on December 4, 2023 and still a current client. A release of information to a government agency was signed and dated by the client on December 4, 2023 but did not indicate a purpose of disclosure.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Divisional Leadership and Quality Assurance Supervisor reviewed internal audit tool to ensure all elements of ROIs were being audited appropriately on a routine basis and confirmed high level of fidelity to State and agency expectations in this regard.
Reviewed expectations for appropriately completed ROIs, including indication of purposes for disclosure, was reviewed during departmental meeting with all staff responsible for completing and reviewing/approving ROIs on 5/6/2024.
Additionally, Clinical Supervisors will review ROIs as part of their chart audits to ensure compliance with all expectations in this regard. QA team will continue to audit continuously and request internal corrective action plans for any identified issues. |