INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 10, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Mid-Atlantic Rehabilitation Services - A.T.P, 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
The facility failed to ensure that two staff persons received the required communicable disease trainings within the regulatory timeframe, based on a review of the facility's Staffing Requirement Facility Report and the employee personnel files.
Employee #2 was hired as the clinical director on October 10, 2016. The employee file did not contain documentation of the HIV/AIDS training at the time of the inspection.
Employee #12 was hired as a counselor on March 17, 2017. The employee file did not contain documentation of HIV/AIDS and TB/STD training at the time of the inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The MARS Project Director will conduct Basic HIV, and TB/STD/Hepatitis training using DDAP approved curriculum by 11/30/18. Employee #2 and Employee #12 will attend these trainings in addition to other staff who need these two trainings. Copies of certificates will be placed in employee files upon completion of trainings. |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
The facility failed to ensure that heaters were permanently mounted or installed as evidenced by a space heater being found in a counselor's office on the lower level by the emergency exit.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Project Director will have all staff sign off on policies and procedures identifying the need to not use space heaters in the facility by 10/31/18. Space Heater will be removed from the office by 10/31/18. |
709.28 (c) 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.
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Observations
The facility failed to document specific information to be released to on consent to release information forms in four of fourteen client records reviewed.
Client # 1 was admitted into the Intake, Evaluation and Referral activity on August 14, 2018 and was discharged August 14, 2018. A release of information form to the funding source and a release of information form to another treatment provider, both signed/dated by the client on August 14, 2018, did not have the specific information to be released identified.
Client #2 was admitted into the Intake, Evaluation and Referral activity on August 13, 2018 and was discharged August 14, 2018. A release of information form to the funding source and a release of information form to another treatment provider, both signed/dated by the client on August 13, 2018, did not have the specific information to be released identified.
Client #3 was admitted into the Intake, Evaluation and Referral activity on September 7, 2018 and was discharged September 8, 2018. A release of information form to the funding source and a release of information form to another treatment provider, both signed/dated by the client on September 7, 2018, did not have the specific information to be released identified.
Client #4 was admitted into the Intake, Evaluation and Referral activity on September 26, 2018 and was discharged September 27, 2018. A release of information form to the funding source and a release of information form to another treatment provider, both signed/dated by the client on September 26, 2018, did not have the specific information to be released identified.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
by 12/1/2018 Project Director will conduct in-service with staff on appropriate completion of release of information forms. Quality Improvement will complete 10% audits of releases to maintain appropriate completion of releases on a monthly basis. |
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
The facility failed to provide treatment plan updates within the regulatory timeframe in six of seven outpatient client records reviewed.
Client #8 was admitted to the outpatient program on June 30, 2017 and was active at the time of inspection. A treatment plan update was completed on January 11, 2018 and the next update was due no later than March 11, 2018. However, the update was not completed until May 17, 2018. Additionally, a treatment plan update was completed on May 17, 2018 and the next update was due no later than August 17, 2018. However, the update was not completed until August 30, 2018.
Client #9 was admitted to the outpatient program on August 1, 2018 and was active at the time of inspection. A treatment plan update was completed on November 11, 2017 and the next update was due no later than January 11, 2018. However, the update was not completed until January 25, 2018.
Client #10 was admitted to the outpatient program on November 3, 2017 and was active at the time of inspection. A treatment plan update was completed on January 26, 2018 and the next update was due no later than March 26, 2018. However, the update was not completed until October 2, 2018.
Client #11 was admitted to the outpatient program on October 9, 2017 and was discharged on April 26, 2018. The comprehensive treatment plan was completed on November 20, 2017 and the first update was due no later than January 20, 2018. However, the update was not completed until February 19, 2018.
Client #12 was admitted to the outpatient program on January 31, 2018 and was discharged on August 17, 2018. The comprehensive treatment plan was completed on January 31, 2018 and the first update was due no later than March 31, 2018. However, the update was not completed at the time of inspection.
Client #13 was admitted to the outpatient program on October 11, 2016 and was discharged on July 17, 2018. A treatment plan update was completed on January 18, 2018 and the next update was due no later than March 18, 2018. However, the update was not completed until May 14, 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director will conduct an in-service with all clinical staff to review policies and procedures regarding time frames for treatment plan and treatment plan updates by 12/01/2018. Quality improvement will complete a 10% audit monthly to review for timeliness of treatment plan completion. |