INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 1, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Three Rivers Youth 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on one of one applicable personnel records reviewed, the facility failed to provide documentation of clinical supervision training for a clinical supervisor who does not meet the required experience supervising others.
Staff #2 was hired as a clinical supervisor on February 7, 2022 and was still in this position at the time of the inspection. After a review of staff #2 ' s personnel record, they do not have two years experience supervising others nor have they completed clinical supervision training.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff #2 will complete the Clinical Supervisor training by 4/8/23. The Director of drug and Alcohol Program will resume the Clinical Supervisor role until Staff #2 meets the requirement to supervise others and completes the training. |
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
Based on one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in client record #1.
Client #1 was admitted on November 4, 2022 and was still active at the time of the inspection. Client #1's record documents a disclosure to medical insurance for billing/funding purposes, but there was not an informed and voluntary consent signed for the funding source.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Three Rivers Youth understands the importance of 709.28. Confidentiality and maintains polices and procedures related obtaining an informed and voluntary consent from the client for the disclosure of information contained in the client record. Client #1 attendance continued to be inconsistent. But, staff was able to have Client #1 sign the aforementioned consent on 2/10/23. The Director will closely monitor consents with staff during weekly supervisions. Also, the Director will review files on a monthly basis or sooner if needed. |
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 one of one applicable client records reviewed, the facility failed to provide follow-up contact in accordance with the facility policy and procedure manual. The policy and procedure manual indicates follow-up contact must be made at thirty, sixty, and ninety days after discharge.
Client #6 was admitted on July 15, 2022 and was discharged on November 7, 2022. The sixty day follow-up contact was due to be completed no later than January 7, 2023 however, this was not completed until January 26, 2023.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Three Rivers Youth has policies and procedures developed to ensure follow-up as outlined in the DDAP regulations. The staff will maintain timely follow-ups with all clients within the 30, 60 or 90 day period. The Director will monitor the process more closely during weekly supervisions and monthly file reviews to make sure staff are following protocol in a timely manner. Also, the agency is in the process of implementing an electronic record system which will allow for reminders on specific documentation. |