INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 5, 2023 through December 6, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, WES Corporation 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 personnel records and the Staffing Requirement Facility Summary Report, the facility failed to ensure all staff received at least 4 hours of tuberculosis, sexually transmitted diseases, and other health related topics training within regulatory time frame.
Employee #5 was hired as a case manager on December 22, 2020. At least 4 hours of TB/STD training was due no later than December 22, 2022; however, there was only documentation, in the record, of .50 hours of TB/STD training, completed on December 7, 2023.
This is a repeat citation from the January 27, 2022 and January 30, 2023 annual licensing renewal inspections.
This finding reviewed with facility staff during the licensing process.
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Plan of Correction
All program staff shall complete the 4 hours of Tuberculosis, Sexually Transmitted Diseases and other health related topics.
WES training manager shall monitor available trainings on a daily basis so staff are registered promptly. The individual responsible for ensuring this will be completed is the Outpatient Director. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on review of personnel records, the facility failed to instruct all staff in the use of the fire extinguisher upon employment in three of three applicable personnel records reviewed.
Employee #2 was hired as a counselor on July 7, 2023. The fire extinguisher training was provided on December 1, 2023.
Employee #3 was hired as a counselor on July 10, 2023. The fire extinguisher training was provided on December 1, 2023.
Employee #4 was hired as a counselor on September 12, 2023. The fire extinguisher training was provided on December 1, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All program staff shall be trained in fire safety and the use of fire extinguishers.
Going forward, program orientation shall be completed the first week of employment and staff shall complete training in fire safety and the use of fire extinguishers. The individual responsible for ensuring this will be completed is the Outpatient Director. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on review of personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies in three of three applicable personnel records reviewed.
Employee #2 was hired as a counselor on July 7, 2023. The emergency preparedness training was not provided at the time of inspection.
Employee #3 was hired as a counselor on July 10, 2023. The emergency preparedness training was not provided at the time of inspection.
Employee #4 was hired as a counselor on September 12, 2023. The emergency preparedness training was not provided at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All program staff shall be trained in all tasks to be preformed during emergencies.
Going forward, new program staff shall receive program orientation the first week of hire including training in all tasks to be performed during emergencies. The individual responsible for ensuring this will be completed is the Outpatient Director. |
709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
Based on an administrative review, the facility failed to document, and make available to the public, an annual report which is to include, but not limited to, a statement disclosing the names of officers, directors, and principal shareholders.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The 2023-2024 Annual Report shall be completed and made available to the public by 9/1/2024. The report will include, but not limited, to a statement disclosing the names of officers, directors and principal shareholders. The individual responsible for ensuring this will be completed is the Outpatient Director. |
709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
Based on a review of client records, the facility failed to ensure the confidentiality of client identity and records by not following the project's written procedures.
The facility policy and procedure manual stated that WES will protect the confidentiality of all information in its records at all stages of collection, use, storage, disclosure, and destruction.
Client #3 was admitted on May 10, 2023 and was active at the time of inspection. There was a progress note, dated June 7, 2023, that included a different active client's biopsychosocial assessment attached.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All client files shall be reviewed on monthly basis to ensure that confidentiality policies and procedures are being followed and that all information information in the client record relates to the client.
Prior to release of client records, Medical Records staff shall review all documentation that is released from client records to ensure that the accurate information is being released. The individual responsible for ensuring this will be completed is the Outpatient Director. |
709.28 (c) 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.
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Observations
Based on a review of client records, the facility failed to obtain a written informed and voluntary consent from the client for the disclosure of information contained in the client record in two of nine client records reviewed.
Client #1 was admitted on March 7, 2023 and was active at the time of inspection. There was a release of information form to the funding source signed and dated by the client on August 16, 2022; however, the form was valid for one year and expired on August 17, 2023. There was documentation of disclosures to the funding source after the consent form expired, but there was no updated consent form signed by the client prior to disclosures from August 18, 2023 through the date of the inspection.
Client #7 was admitted on March 5, 2022 and was active at the time of inspection. There was a release of information form to the funding source that was signed and dated by the client on March 23, 2022; however, the form was valid for one year and expired on March 23, 2023. There was documentation of disclosures to the funding source after the consent form expired, but there was no updated consent form signed by the client prior to disclosures from March 24, 2023 through the date of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All program clients shall have updated written informed and voluntary consents documented in their medical record.
Going forward all clients shall sign written informed and voluntary consents as part of the intake process and will update these on an annual basis. The individual responsible for ensuring this will be completed is the Outpatient Director. |
709.28 (c) (1) 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 must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom a disclosure was to be made to on a release of information form in one of nine client records reviewed.
Client #1 was admitted on March 7, 2023 and was active at the time of inspection. A blank release of information form was signed and dated by the client on August 2, 2023; however, the name of the person, agency, or organization to whom the disclosure was to be made was not documented on the form.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All program clients shall sign release of information forms that include, names of the person, agency or organization to whom disclosure is made.
All release of information forms shall be updated on an annual basis. The individual responsible for ensuring this will be completed is the Outpatient Director. |
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 must 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 the specific information to be released on a consent to release information form in one of nine client records reviewed.
Client #2 was admitted on March 25, 2023 and was active at the time of the inspection. A release of information form to a school was signed and dated by the client on November 1, 2023; however, the specific information to be disclosed was not documented on the form.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All program clients shall have updated written informed and voluntary consent to release information forms that include the specific information to be disclosed. These release of information forms shall be updated on an annual basis. The individual responsible for ensuring this will be completed is the Outpatient Director. |
709.28 (c) (4) 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 must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document a dated signature of the client on release of information forms in six of nine client records reviewed.
Client #2 was admitted on March 25, 2023 and was active at the time of inspection. Release of information forms to a funding source and a government agency were signed and dated by a witness on March 29, 2023; however, the dated signature of the client was not documented on either form. Additionally, a release of information form to a school was signed and dated by a witness on November 1, 2023; however, the dated signature of the client was not documented on the form.
Client #3 was admitted on May 10, 2023 and was active at the time of inspection. Release of information forms to a funding source and a government agency were signed and dated by a witness on May 10, 2023; however, the dated signature of the client was not documented on either form.
Client #4 was admitted on April 4, 2023 and was discharged on July 25, 2023. A release of information form to a funding source was signed and dated by a witness on April 28, 2023; however, the dated signature of the client was not documented on the form.
Client #6 was admitted on March 1, 2023 and was discharged on July 20, 2023. Release of information forms to an outside person and a probation officer were signed and dated by a witness on March 6, 2023; however, the dated signature of the client was not documented on either form. Additionally, a release of information form to a school was signed and dated by the client on March 7, 2023, a release of information form to a funding source was signed and date by a witness on March 26, 2023, and a release of information form to a government agency was signed by a witness on April 11, 2023; however, the dated signature of the client was not documented on any of the forms.
Client #8 was admitted on July 7, 2023 and was discharged on December 1, 2023. Release of information forms to a funding source and a government agency were signed and dated by a witness on July 5, 2023; however, the dated signature of the client was not documented on either form. Additionally, release of information forms to a urinalysis laboratory, a school, a probation officer, and an emergency contact were signed and dated by a witness on July 7, 2023; however, the dated signature of the client was not documented on any of the forms.
Client #9 was admitted on March 5, 2023 and was discharged on August 9, 2023. Release of information forms to a urinalysis laboratory, a school, a government agency, and an emergency contact were signed and dated by a witness on May 9, 2023; however, the dated signature of the client was not documented on any of the forms.
This is a repeat citation from the January 27, 2022, and January 30, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All client files shall be updated to include release of information forms that include the signature and date that the client and/or guardian signed the form.
These forms shall be updated as stated above on an annual basis. The individual responsible for ensuring this will be completed is the Outpatient Director. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to ensure that treatment and rehabilitation plans were reviewed and updated at least every sixty days in five of six applicable client records reviewed.
Client #1 was admitted on March 7, 2023 and was active at the time of inspection. A treatment plan update was completed on April 10, 2023, and the next update was due no later than June 10, 2023; however, the update was completed on July 17, 2023. Additionally, the next treatment plan update was due no later than September 17, 2023; however, the update was completed on October 6, 2023.
Client #2 was admitted on March 25, 2023 and was active at the time of inspection. The individual treatment and rehabilitation plan was completed on April 10, 2023, and the first update was due no later than June 10, 2023; however, the update was completed on July 18, 2023. Additionally, the next treatment plan update was due no later than September 18, 2023; however, the update was completed on October 6, 2023.
Client #3 was admitted on May 10, 2023 and was active at the time of inspection. A treatment plan update was completed on September 25, 2023, and the next update was due no later than November 25, 2023; however, the update was completed on November 30, 2023.
Client #6 was admitted on March 1, 2023 and was discharged on July 20, 203. A treatment plan update was completed on April 11, 2023, and the next update was due no later than June 11, 2023; however, the update was not completed prior to discharge.
Client #8 was admitted on July 7, 2023 and was discharged on December 1, 2023. The individual treatment and rehabilitation plan was completed on August 23, 2023, and the first update was due no later than October 23, 2023; however, the update was completed on November 8, 2023.
This is a repeat citation from the January 28, 2021, January 27, 2022, and January 30, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All client treatment and rehabilitation plans shall be updated immediately.
Going forward all client treatment and rehabilitation plans shall be updated on a monthly basis. The individual responsible for ensuring this will be completed is the Outpatient Director. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for documenting the dated signature of the client on release of information forms were submitted and approved by the Department for the January 27, 2022 and January 30, 2023 annual licensing inspections. Failing to document the dated signature of the client on release of information forms was again found to be a deficiency in the December 5, 2023 - December 6, 2023 licensing inspection.
A plan of correction for treatment and rehabilitation plans needing to be reviewed and updated at least every 60 days were submitted and approved by the Department for the January 28, 2021, January 27, 2022, and January 30, 2023 annual licensing inspections. Failing to ensure that treatment and rehabilitation plans were reviewed and updated at least every 60 days was again found to be a deficiency in the December 5, 2023 - December 6, 2023 licensing inspection.
A plan of correction for completing the communicable disease trainings within the regulatory timeframe was submitted and approved by the Department for the for the January 27, 2022 and January 30, 2023 annual licensing inspections. Failing to complete the communicable disease trainings within the regulatory timeframe was again found to be a deficiency in the December 5, 2023 - December 6, 2023 licensing inspection.
This is a repeat citation from the January 30, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
WES shall complete all elements of the plan of correction by the dates indicated on the plan.
WES Program Director and Director of Quality Management shall meet on a weekly basis to monitor completion of the plan to ensure the corrections are made. |