INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 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, Serenity Mountain Recovery Center 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 and the Staffing Requirement Facility Summary Report, the facility failed to ensure all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD training within the regulatory time frame in one of five applicable personnel records reviewed.
Employee #5 was hired as a counselor assistant on October 18, 2021. At least 4 hours of TB/STD training was due no later than October 18, 2022. However, the training was not completed at the time of the inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Clinical Director and Clinical Supervisor discussed overall importance of trainings and continuing education with all employees following this inspection. Employee and the Clinical Director specifically discussed the need to complete TB/STD training promptly. These training hours will be completed by the Employee no later than June 30, 2023. Moving forward, our office manager/HR will ensure all employee trainings are up-to-date per DDAP compliance. HR will review this with all employees quarterly. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel files, the facility failed to ensure that annual written individual performance evaluations, which are to be reviewed and signed by the employee, were completed in one of three applicable personnel records reviewed.
Employee #5 was hired as a Counselor Assistant on October 18, 2021. There was no documentation that the annual written individual performance evaluation was completed for the prior year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The counselor assistant referenced, recieved weekly supervision in which her performance was continuously evaluated and goals were set. Due to her yearly evaluation not being documented, this was completed with employee on 4/27/2023 by the clinical director. All yearly evaluations will be completed and submitted to HR at the time of their annual review. This will be completed by the clinical supervisor for every clinical employee. |
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 the date, event, or condition upon which the consent will expire on consent to release information forms in ten of ten client records reviewed.
Every client record reviewed included a release of information to the funding source; however, on each consent form in every record, there was no date, event, or condition upon which the consent to release information form would expire.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Consent forms were changed and updated to include expiration dates. These forms now state the date, event, and condition in which the forms will expire. This change was completed on 05/09/2023. Current clients have signed the updated forms with the clinical staff. The clinical supervisor reviewed these forms to ensure the correction was made and implemented. Moving forward, the clinical supervisor will review documentation, including consent forms, to prevent reoccurance. |