INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 29, 2009 through June 30, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, RHD Lower Merion Counseling Services 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 and a plan of correction is due on July 29, 2009.
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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 personnel record, the facility failed to make sure that all staff is trained for 6 hours in HIV/AIDS and at least 4 hours of TB/STD training in the required amount of time in one of seven records reviewed.
Findings:
Seven personnel records were reviewed on June 29, 2009. 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. Employee # 6 was hired April 17, 2008 and is required to have HIV/AIDS training by April 17, 2009 and as of June 29, 2009 did not have the required training. This was not documented in personnel record reviewed.
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Plan of Correction
This training was completed by the staff in question on 07/14/09.
Effective 8/1/09, employee charts will be reviewed by their supervisor quarterly to ensure that all staff complete training as required.
These actions will bring the agency into full compliance with the standard by July 14, 2009. |
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.
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Observations
Based on a review of client records, the facility failed to document follow-up information in one of one client records.
Findings:
Five client records were reviewed on June 30, 2009. Follow-up information was required in one client records. In accordance with the facility's policy follow-ups will be done 30 days after discharged if not being referred. Follow-up information was documented late in record #4 as client #4 was discharged on 12/17/08 and follow-up documentation was completed on 6/26/09.
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Plan of Correction
Effective 7/15/09 all closed D&A charts will be reviewed by the CQI Specialist within 25 days of discharge to ensure that the follow-up letter has been sent to the consumer.
These actions will bring the agency into full compliance with the standard by July 15, 2009. |