INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 25, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Schuylkill Health System Center for Counseling Services was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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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
Six personnel records were reviewed on May 25, 2016. Five 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, a counselor, was hired September 9, 2014. HIV/AIDS and TB/STD training was due to be completed no later than September 9, 2015. The facility failed to provide documentation of HIV/AIDS and TB/STD training as of the date of the licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. During initial employee orientation all new employees will be made aware of training requirement time frame for the required training.
Responsible Person: Facility Director & Employee
2. Employees will establish log on information to the DDAP Training Web Portal and receive instruction on how to determine course availability and registration process.
Responsible Person: Facility Director & Employee
3. At the time of three month initial evaluation training status will be reviewed and prioritized if not completed.
Responsible Person: Facility Director & Employee
4. Provider will consider development of internal resourced curriculum in accordance with Licensing Alert 1-97 to use as a method to insure compliance. Responsible Person: Facility Director & Education Department
5 Compliance monitoring will occur quarterly with employee to establish progress toward compliance. Responsible Person: Employee & Facility Director |
711.93(c)(1)(i) LICENSURE Confidentiality - Client Identity/Records
711.93. Client records.
(c) Confidentiality.
(1) A written procedure shall be developed by the project director which complies with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(i) Confidentiality of client identity and records.
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Observations
Ten client records were reviewed on May 25, 2016. The facility failed to comply with 42 CFR subpart C 2.31 (8) and 2.32 in 10 of 10 records reviewed. A patient written consent must be accompanied by the following written statement:
42 CFR subpart C 2.31 (8) - A statement that the consent is subject to revocation at any time except to the extent that the program or person which is to make the disclosure has already acted in reliance on it.
42 CFR subpart C 2.32 - This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1.The required statement will be added to all Release of Information forms used by the program by 6/24/16. Responsible Person: Facility Director & Clerical Staff.
2.Staff In service training on revised consent form on 6/27/16. Responsible Person: Director and Clinical Supervisor.
3.Replace all current release forms with revised consent forms on 6/28/16. Responsible Person Facility Director & Clerical Staff.
4.All new admissions begin signing revised consent forms 7/5/16. Responsible Person: Facility Director,Clinical Supervisor, Clinical Staff.
5. Patients currently active in treatment will signed revised consent forms at their first individual clinical session after 7/5/16. Responsible Person: Facility Director,Clinical Supervisor and Clinical Staff.
6. Compliance monitoring will be achieved via supervisory chart review in supervision session as well as chart audit monthly. 7/5/16 ongoing. Responsible Person: Clinical Supervisor.
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