INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection starting on February 8, 2021 and concluding on February 19, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Care Center dba SPHS Care 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 the Staffing Requirements Facility Summary Report and an interview with facility staff, the facility failed to document TB/STD and/or HIV/AIDS training in four of seven client records.
Staff #13 was hired as a counselor on May 17, 2018. TB/STD and HIV/AIDS training was due to be completed by May 17, 2019. There was no documentation of HIV/AIDS and TB/STD training for staff #13.
Staff #14 was hired as a counselor on August 19, 2019. TB/STD training was due to be completed August 19, 2020. There was no documentation of TB/STD training for staff #14.
Staff #16 was hired as a counselor on June 4, 2019. HIV/AIDS training was due to be completed by June 4, 2020. There was no documentation of HIV/AIDS training for staff #16.
Staff #17 was hired as a counselor on September 4, 2019. HIV/AIDS training was due to be completed by September 4, 2020. There was no documentation of HIV/AIDS training for staff #17.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the annual inspection conducted on February 24-25, 2020.
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Plan of Correction
Due to the COVID Pandemic several HIV/AIDS/STD trainings were cancelled and unable to be re-scheduled with in the timeframe from prior plan of care. By 05/01/2021 a mandatory staff meeting will be held with all staff to re-review mandatory training guidelines. Staff members who need to be scheduled for their Mandatory Communicable Disease Training will be scheduled and completed by 05/31/2021. All new clinical staff will be scheduled for their Mandatory Communicable Disease training within the first year that they are employed. The Clinical Supervisor and Director will be responsible for this plan of correction and ongoing monitoring of same. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report and an interview with Facility Staff, the facility failed to document at least 25 hours of annual counselor training in 6 of 9 records.
Employee #11 was hired as a counselor on August 17, 2018. Employee #11 had documentation of 6 hours of training for the 2019/2020 training year.
Employee #12 was hired as a counselor on April 2, 2016. Employee #12 had documentation of 22 hours of training for the 2019/2020 training year.
Employee #13 was hired as a counselor on May 17, 2018. Employee #13 had documentation of 23 hours of training for the 2019/2020 training year.
Employee #15 was hired as a counselor on February 19, 2018. Employee #15 had documentation of 7 hours of training for the 2019/2020 training year.
Employee #18 was hired as a counselor on November 19, 2018. Employee #18 had documentation of 0 hours of training for the 2019/2020 training year.
Employee #19 was hired as a counselor on September 2, 2015. Employee #19 had documentation of 0 hours of training for the 2019/2020 training year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Due to the COVID Pandemic and CDC constraints many trainings were cancelled and not offered virtually. By 05/01/2021 a mandatory staff meeting will be held with all staff to re-review mandatory training and staff development guidelines. Moving forward, staff will complete the required number of training hours each training year. The Clinical Supervisor/Director will be responsible for ongoing monitoring by auditing the training log every 6 months. |
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 a review of client records, the facility failed to document a written informed and voluntary consent from the client for the disclosure of information contained in one of nine client records.
Client #4 was admitted on May 14, 2020 and discharged on September 18, 2020. " Verbal consent " was observed to be documented on releases of information documented in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Due to the COVID Pandemic some services had to be rendered off site. By 05/01/2021 a mandatory staff meeting will be held with all staff to re-review Drug and Alcohol Confidentiality and the importance of obtaining physical signatures moving forward. In the event that a client is unable to come on-site a paper consent will be mailed to the client to physically sign and return. All staff will sign the meeting minutes verifying understanding procedure. It is the expectation that staff who were absent will review in individual supervision with the Clinical Supervisor and Director. Clinical Supervisor and Director will ensure compliance through on going chart audits and reviews moving forward. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document a written informed and voluntary consent, including a dated signature from the client for the disclosure of information contained in one of nine client records.
Client #4 was admitted on May 14, 2020 and discharged on September 18, 2020. " Verbal consent " was observed to be documented on releases of information documented in the client record. There was no client signature present.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Due to the COVID Pandemic some services had to be rendered off site. By 05/01/2021 a mandatory staff meeting will be held with all staff to re-review Drug and Alcohol Confidentiality and the importance of obtaining physical signatures moving forward. In the event that a client is unable to come on-site a paper consent will be mailed to the client to physically sign and return. All staff will sign the meeting minutes verifying understanding procedure. It is the expectation that staff who were absent will review in individual supervision with the Clinical Supervisor and Director. Clinical Supervisor and Director will ensure compliance through on going chart audits and reviews moving forward. |