INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 2-3, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Stepping Stones Unit @ Meadville Medical 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 training records and the facility ' s Staffing Requirements Facility Summary Report, the facility failed to ensure all staff persons received a minimum of 6 hours of HIV/AIDS training and/or at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in one of one applicable record reviewed.
Employee # 4 was hired as a counselor assistant on September 27, 2021 and was due to have HIV/AIDS training and TB/STD training no later than September 27, 2022. Neither the HIV/AIDS training nor the TB/STD training was completed at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
#0067
Facility Director will assume responsibility for facilitation of utilization of DDAP curriculum for these trainings. This will include present employee mentioned and all future new employees who require the infectious diseases training. This will occur on an ongoing basis to supplement any lack of available classes presented online or face-to-face by outside entities. Employee #4 has as of this writing completed the HIV training newly made available by DDAP. |
711.93(a)(7) LICENSURE Follow-up Information
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(7) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow-up information in three of three applicable outpatient client records.
The policy states follow up will be completed at one month, six months and one year. One month followup up was not completed for Client #11, 12, 14.
Client # 11 was admitted on May 17, 2022 and was discharged on September 21, 2022. There was no follow-up information documented at the time of the inspection.
Client # 12 was admitted on June 1, 2022 and was discharged on September 12, 2022. There was no follow-up information documented at the time of the inspection.
Client # 14 was admitted on April 26, 2022 and was discharged on July 25, 2022. There was no follow-up information documented at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
#0989
Process was reviewed with Unit Secretary who is responsible for logging in the contact made. Follow up had been completed but as the observation states there was no documentation to substantiate this. Also after review of levels of response from patients post-discharge it was determined that the one-year follow-up would be discontinued since this is the period with the least amount of responses received. Policy revised to reflect this change.
Program Supervisor will inspect the log book every month to insure that followups have been sent on the first of each month or nearest business day to that date and inspect at random times in addition to the monthly review.
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