INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 13 - 14, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Family Services of Warren County 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 and a plan of correction is due on May 15, 2009.
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Plan of Correction
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709.28(c)(2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to document consents to release information which identified the specific information to be released to funding entities and
exceeded the limits of 4 Pa Code subsection 255.5 in three of six client records reviewed.
The findings include:
Six client records were reviewed on April 14, 2009. Consents to release information were required in six client records. The only information to be released to the funding entity includes: whether the client is or is not in treatment, client's prognosis, the nature of the project, a brief description of the client's progress, and a short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse. The facility released information to a funding entity that exceeded the limitations of 4 Pa Code subsection 255.5 (b) in client records # 1, 2 and 6.
In client record # 1, the results of evaluation and recommendations were released to the SCA funding entity; which exceeded the limitations imposed at 4 Pa. Code Subsection 255.5 (b).
In client record # 2, the results of evaluation and recommendations were released to the funding entity which exceeded the limitations imposed at 4 Pa. Code Subsection 255.5(b).
In client record # 6, the results of evaluation and recommendations were released to the funding entity which exceeded the limitations imposed at 4 Pa Code Subsection 255.5 (b).
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Plan of Correction
1. With regards to release of information for client records # 1, 2 and 6 to funding sources i.e. SCA, Insurance Companies which the facility exceeded the limitations of 4 PA Code subsection 255.5 (b) the following measures have been taken to place the facility in compliance. 1. The release of information for funding sources presented to new clients at intake has been corrected to properly reflect the Law PA 255 ? completed on April 14, 2009.; 2. The release of information for funding sources for all active clients has been corrected to properly reflect the Law PA 255.5, therefore, all active clients including client records #1, 2 and 6 have or will sign a new release of information for funding sources by May 31, 2009.; 3. Supervisor of the Substance Abuse Program met with each counselor to review Law PA 255.5 in regards to release of information to funding sources and other entities that fall under the law. In addition, each counselor was instructed to take extreme care in paying attention in completing releases of information appropriately in order to maintain the client's confidentiality.; 4. The Supervisor of the Substance Abuse Program will perform quality assurance checks of client's records on a regular basis, at least once a month, to assure compliance with confidentiality. |
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 and an interview with the facility director, the facility failed to provide documentation of HIV/AIDS and TB/STD training in four of six personnel records.
The findings include:
Seven personnel records were reviewed on April 13, 2009. Six personnel records were required to have documentation of HIV/AIDS and TB/STD training. The facility failed to provide documentation of TB/STD training in personnel record # 3. The facility did not provide documentation of the required HIV/AIDS training in personnel records # 5, 6 and 7.
Employee # 3 is a counselor and was hired February 6, 2008. TB/STD training was due to be completed by February 6, 2009. The facility failed to provide documentation of TB/STD training.
Employee # 5 is support staff and was hired on November 1, 2004. HIV/AIDS training was due to be completed by November 1, 2006. The facility failed to provide documentation of HIV/AIDS training.
Employee # 6 is support staff and was hired on December 16, 2005. HIV/AIDS training was due to be completed by December 16, 2007. The facility failed to provide documentation of HIV/AIDS training.
Personnel record # 7 is a volunteer and started with the facility on February 1, 2005. HIV/AIDS training was due to be completed by February 1, 2007. The facility failed to provide documentation of HIV/AIDS training.
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Plan of Correction
2. Concerning personnel record #3 not having the required provided documentation of TB/STD training and personnel records # 5, 6 and 7 not having the required provided documentation for HIV/AIDS the following actions will be taken. 1. Employee # 3, the counselor has signed up for BDAP approved TB/STD training to be held in Erie, PA on Thursday, May 14, 2009.; 2. Employees #5 and 6, support staff, have signed up for the BDAP training for HIV/AIDS on Tuesday, November 17, 2009 in Cranberry, PA.; 3. Personnel record #7, volunteer ? Medical Director, will be attending a medical conference on May 28, 2009 for HIV/AIDS.; 4. The Supervisor of the Substance Abuse Program and the Executive Director will monitor more closely the required training needed for Drug and Alcohol Licensing Regulations within the required time frame for current and new employees.; 5. Supervisor of the Substance Abuse Program will conduct a review each month with counselors, support staff and volunteers to assure required regulation trainings and required training hours to assure yearly compliance with continuing education for clinical staff are being met.; 6. Executive Director and Supervisor of the Substance Abuse Program are scheduled to meet the Director of the Single County Authority on Monday, May 11, 2009. We will discuss the possibility of coordinating and holding a BDAP approved HIV/AIDS training during the summer or early fall in the Warren/Forest County Area to meet our agency requirements before November and the need for this training topic for other behavioral health agencies in the area or surrounding area as well. |