INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 21, 2013, by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, North Philadelphia Health System - Torre De La Raza 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 upon the review of employee records, the facility failed to ensure that a core curriculum in clinical supervision was completed by one of one clinical supervisors who did not have at least two years of clinical supervision experience.
The findings include:
An administrative review, which included a review of employee records, was conducted on August 6, 2013. The facility failed to ensure that employee # 3, who had less than 2 years of clinical supervision training, completed a core curriculum in clinical supervision.
Employee # 3 was hired as a clinical supervisor on June 11, 2012. The record did not include documentation that employee # 3 completed a core curriculum in clinical supervision as of the date of inspection.
The findings were confirmed by the Vice President during the record review.
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Plan of Correction
The clinical supervisor will be scheduled for the next sponsored DDAP clinical supervisors training or will complete alternative approved traing program on or before 3/31/2014.
The clinical supervisor has been instructed to register for the December 2013 training offered in Valley Forge.
The Residential Director will be responsible for and monitoring completion; and for checking the BTMS system for scheduled training dates in the furture to ensure that new supervisors recieve required training. |
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 upon the review of employee records, the facility failed to provide documentation of a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training in one of two employee records reviewed.
The findings include:
Two employee records requiring documentation of HIV/AIDS and TB/STD training were reviewed during an administrative review that was conducted on August 8, 2013. The facility failed to provide documentation of HIV/AIDS and TB/STD training in record # 7.
Employee # 7 was hired as a counselor on September 1, 2011 and was required to obtain a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training by September 1, 2012. The record did not include any documentation of HIV/AIDS or TB/STD training as of the date of inspection.
The findings were confirmed by the Vice President during the record review.
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Plan of Correction
The staff identified have been assigned to complete HIV/AIDS and STD training during the September and October 2013 New employee orientation sessions. The clinical supervisors and the Department Administrator will monitor completion of mandatory trainings of all new hires on a quarterly basis. Full compliance will be achieved by November 1, 2013. |
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 upon the review of employee training records, the facility failed to document that counselors obtained 25 clock hours of training annually in one of one employee records.
The findings include:
The project's training year runs from January 1 to December 31.
One counselor's training record was reviewed on August 6, 2013. The facility failed to ensure that employee # 7 obtained at least 25 clock hours of training in 2012.
Employee # 7 was hired as a counselor on September 1, 2011. Employee # 7 was required to complete 25 clock hours of training during the 2012 training year. The record did not include documentation of any training hours for 2012 as of the date of inspection.
The findings were confirmed by the Vice President during the record review.
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Plan of Correction
The clinical supervisor will review progress toward achieving training hours once a month during supervision beginning immediately and on an ongoing basis. Training attendance will be mandated by and monitored by the clinical supervisor. Quarterly review of the training records will be conducted by the administrative assistant for the department who will report training hours to the clinical supervisor beginning in September and ongoing. Clinical staff will be provided a list of approved on line training sites by September 30, 2013 and provided monthly updates of available training beginning September 2013 by the administrative assistant. Full compliance for training hours will be achieved for calendar year 2013. |
711.53(c)(2) LICENSURE Consent to Release Information - Informed/Vol
711.53. Client records.
(c) Confidentiality.
(2) 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 upon the review of client records, the facility failed to obtain informed and voluntary consent to release information forms that were complete and valid in three of four client records.
The findings include:
Four client records requiring informed and voluntary consent to release information forms were reviewed on August 21, 2013. The facility failed to obtain consent to release information forms that were complete and valid in client records # 1, 3 and 4.
Client # 1 was admitted on July 25, 2013, and was still an active client on the date of inspection. The record included the following consent to release information forms that were incomplete:
1) A consent to release information form signed by the client on July 25, 2013 did not include the specific information disclosed or the purpose of disclosure.
2) Another consent to release information form signed on July 25, 2013 did not include the specific information disclosed.
Client # 3 was admitted on July 2, 2013, and was still an active client on the date of inspection. The record included the following consent to release information forms that were incomplete or that contained inaccurate information:
1) A consent to release information form signed on July 9, 2013 did not include the specific information disclosed or the purpose of disclosure.
2) Another consent to release information form signed on July 9, 2013 did not include the purpose of disclosure.
3) A third consent to release information form signed on August 16, 2013 did not include the specific information disclosed or the purpose of disclosure.
4) The client record contained three consent to release information forms dated July 2, 2013 that were for another client and were misfiled in this client record.
Client # 4 was admitted on July 3, 2013, and was still an active client on the date of inspection. The record included the following consent to release information forms that were incomplete:
1) A consent to release information form signed on July 16, 2013 did not include the purpose of disclosure.
2) A consent to release information form signed on August 6, 2013 did not include the specific information disclosed.
The findings were reviewed with the clinical supervisor during the exit interview and were not disputed.
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Plan of Correction
Policy regarding the completion of release of information forms were reviewed with the clinical supervisors by the Residential Director on August 23, 2013
All misfiled consents to release information were removed from the records on 8/21/2013.
Inservice training was provided to the counseling staff regarding release of information forms during the week of August 26, 2013.
Clinical supervisors will review and monitor release forms during clinical supervision on a montly basis begining immediately and ongoing.
Full compliance will be achieved by September 30, 2013. |
711.53(c)(3) LICENSURE Copy of Client Consent
711.53. Client records.
(c) Confidentiality.
(3) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
Based upon the review of client records, the facility failed to document that the client was offered a copy of all client consent to release information forms in three of four client records.
The findings include:
The facility verified whether or not a client was offered a copy of a consent form via the use of two check-off boxes on the consent form. One check-off box indicated that the client accepted a copy and the other check-off box indicated that the client did not accept a copy.
Four client records were reviewed on August 21, 2013. The facility failed to document that clients were offered a copy of all client consent to release information forms in client records # 1, 3 and 4.
Client # 1 was admitted on July 25, 2013, and was still an active client on the date of inspection. The facility was unable to verify that the client was offered a copy of the following consent form:
1) A consent to release information form signed on July 25, 2013 - neither box was checked off.
Client # 3 was admitted on July 2, 2013, and was still an active client on the date of inspection. The facility was unable to verify that the client was offered a copy of the following consent to release information forms:
1) A consent to release information form signed on July 9, 2013 - neither box was checked off.
2) A consent to release information form signed on August 16, 2013 - neither box was checked off.
3) A consent to release information form signed on August 16, 2013 - neither box was checked off.
Client # 4 was admitted on July 3, 2013, and was still an active client on the date of inspection. The facility was unable to verify that the client was offered a copy of the following consent to release information forms:
1) A consent to release information form signed on August 6, 2013 - neither box was checked off.
The findings were reviewed with the clinical supervisor during the exit interview and were not disputed.
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Plan of Correction
Policy regarding the completion of release of information forms were reviewed with the clinical supervisors by the Residential Director on August 23, 2013. Inservice training was provided to the counseling staff regarding release of information forms during the week of August 26, 2013. Clinical supervisors will review and monitor release forms during clinical supervision on a montly basis begining immediately and ongoing. Full compliance will be achieved by September 30, 2013. |