INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 19, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Independent Family Services, Inc. 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, the facility failed to provide documentation of HIV/AIDS and TB/STD training in one of six personnel records reviewed.
The findings include:
Six personnel records were reviewed on November 19, 2015. Three personnel records were required to have documentation of HIV/AIDS and TB/STD training. The facility did not provide documentation of the required HIV/AIDS and TB/STD training in personnel record # 6.
Employee # 6 was hired as a counselor on July 17, 2014. HIV/AIDS and TB/STD training was due to be completed no later than July 17, 2015. The facility failed to provide documentation of HIV/AIDS and TB/STD training.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
704.11(c)(1) Mandatory Communicable Disease Training
Staff Development Program
All new hires or company employees transferring to the AOD Outpatient Program will obtain their Mandatory Communicable Disease Training within one year of their hire date if they are a counselor/volunteer or two years for any other personnel. This training goal will be developed in their individual training plans and monitored through their staff development and supervision. Trainings will be scheduled through the DDAP Training System. If there is not an available DDAP training date within the specified regulatory requirements, the employee or volunteer will attend a training elsewhere to maintain compliance.
The AOD Counselor cited in the November 19, 2015 licensure renewal inspection will have the Mandatory Communicable Disease Training completed by July 10, 2016, his anniversary hire date.
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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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent in one of five records reviewed.
The findings include:
Six client records were reviewed on November 19, 2015. Five records were reviewed for informed and voluntary consent forms. The facility failed to document an informed and voluntary consent in client record # 5.
Client # 5 was admitted into treatment on 4/20/15 and was discharged on 8/5/15. The client's record documented a letter sent to a Suboxone treatment provider, dated 6/11/15. The letter disclosed the client's participation in counseling services at the facility. The facility failed to document an informed and voluntary consent prior to sending the letter to the Suboxone treatment provider. Additionally, the client's record contained a consent to release information to the same Suboxone treatment provider, signed and dated 8/5/15. This consent form failed to include the date, event or condition upon which the consent would expire.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
709.28(c) Confidentiality
The Facility Director and Project Director met with the AOD staff after the 11/19/2015 state inspection to review the confidentiality regulation cited and the AOD Outpatient Program's policy of obtaining client signed consents for the release of information.
Upon the intake appointment, the client will meet with the Outpatient Coordinator to determine community resources currently assisting the client. At this time, signed consents will be obtained for all community resources relevant to the client's care. The client is assigned an individual counselor during the intake appointment. Upon the initial appointment, the individual counselor will review the obtained consents with the client and determine if any additional services and respective consents will need to be obtained. Henceforth, the counselor and client will review upon the Treatment Plan Update if any additional services and respective consents will need to be obtained or renewed. If during the course of AOD treatment the client discloses a community resource involved in assisting them relevant to their AOD treatment, a signed consent will be obtained.
After the Outpatient Coordinator completes the intake process, the Facility Director will review the medical record and determine if the appropriate consents have been obtained and are signed by the client before any information is released by the facility. Henceforth, no documentation will be released until the consent has been reviewed by the Facility Director for completeness. This process will be integrated into the AOD Continuous Quality Improvement program. |