INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on February 17, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, TREHAB 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:
|
Plan of Correction
|
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.
|
Observations
Based on the review of five personnel records, the project failed to ensure that one employee received a minimum of six hours of HIV/AIDS and at least four hours of tuberculosis, sexually transmitted diseases and other health related topics training within the first year of employment.
Employee #4 was hired on February 3, 2020 and was due to have the communicable disease trainings no later than February 3, 2021; however, there was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
The findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Employee #4 had not completed the required six (6) hours of HIV/AIDS and four (4) hours of TB/STD and other health related topics within the first year of employment foremost due to the COVID-19 pandemic and Employee #4 vocalizing fear of attending in-person trainings and placing herself at risk for COVID-19 exposure as an individual who fell into one of the CDC "high risk" categories. Employee #4 had developed a training plan when hired 2/4/2020 and subsequently for TY 20-21 that was reviewed with Clinical Supervisor; Employee #4 indicated understanding that these are required trainings to be obtained within the first year of employment, however Employee #4 was not successful with locating and registering for appropriate virtual communicable disease trainings that would be approved by DDAP. In preparation for submitting a plan of correction and to achieve compliance, Employee #4 was made aware of the licensing citation given during inspection of facility 582054 on 2/17/2021 by Clinical Supervisor on 2/19/2021. Subsequently, Employee #4 and Clinical Supervisor discussed deficiency for 704.11(c)(1) Mandatory Communicable Disease Training in greater detail upon completion of licensing review process that concluded on 2/22/2021 at outpatient facility 667065. Employee #4 vocalized increased confidence for personal safety and wellness due to receiving both doses of COVID-19 vaccination in January/February 2021. Action steps to correct deficiency were developed as follows: 1. Employee #4 is registered for HIV Fundamentals ? 6 hour in-person training ? PCB approved on 5/7/2021 from 9:00 AM ? 4:00 PM at The Wright Center, Scranton, PA. 2. Employee #4 is registered for Communicable Diseases ? Accurate and Current Education on TB, Hepatitis and STDs ? 6 hour in-person training ? PCB approved on 5/14/2021 from 9:00 AM ? 4:00 PM at The Wright Center, Scranton, PA. Both registrations have been confirmed by Clinical Supervisor. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
|
Observations
Based on the review of client records, the project failed to document written acknowledgement by clients that the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion in two of seven client records reviewed.
Client #3 was admitted on August 7, 2019 and was an active client at the time of the inspection.
Client #4 was admitted on April 25, 2019 and was discharged on July 19, 2020
The findings were reviewed with project staff during the licensing process.
|
Plan of Correction
On 2/22/2021, during the weekly clinical staffing meeting held via Zoom, Clinical Supervisor discussed deficiencies received on 2/17/2021 during licensing review of facility 582054 and on 2/22/2021 during licensing review of facility 667065 regarding 709.30. Client rights. The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights. (2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion. Departmental clinical and support staff were made aware by Clinical Supervisor that two (2) client records for clients admitted to treatment prior to March 2020 did not have the updated Client Orientation / Client Rights document with the comprehensive discrimination statement, resulting in a citation. Department clinical and support staff were instructed that the most recent Client Orientation / Client Rights document updated in March 2020, must be reviewed with and signed by all active clients to ensure understanding of their rights and outpatient discrimination policy. Clinical staff were instructed to review the charts of their active clients and begin completing updated Orientation / Client Rights documents with clients as necessary. The expectation by Clinical Supervisor is that clinical staff will have this task completed with active clients and all records will be corrected by 3/31/2021. Clinical Supervisor, Quality Management Coordinator and a designated clinical support staff person are scheduled to review active client charts to ensure they are updated on 4/2/2021.
|