INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on March 2, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Pennsylvania Counseling Services 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 a review of ten personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that one employee received the minimum of 6 hours of HIV/AIDS training within the regulatory timeframe.
Employee # 7 was hired as a counselor on July 29, 2019 and was due to have the communicable disease training no later than July 29, 2020. There was documentation in the personnel record that the completion of the HIV/AIDS training was not completed until November 9-10, 20202.
These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
Employee #7 was registered for a 2/5/20 HIV/AIDS training which was canceled. Due to the pandemic, many PCS staff had difficulty completing the required trainings. The Director of Outpatient Services is currently working with the PCS Training Department to develop curriculum to be approved by DDAP so that in-house communicable disease trainings can be offered to PCS staff to ensure completion within the regulatory timeframes. |
705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
|
Observations
Based on a physical plant inspection on March 9, 2021, the facility failed to ensure that all counseling sessions could not be seen or heard from outside the counseling room as a group room 012 had a window in the door that was not covered and Room 011 had a client zoom session happening with the door open.
These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
The group room 012 window was covered on March 9, 2021. The Director of Outpatient Services oversaw that all program staff were re-educated on confidentiality during a 3/25/21 team meeting. The office manager will do random monthly checks to ensure that confidentiality is maintained while clients are in sessions. |
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.
|
Observations
Based on a review of seven client records, the facility failed to ensure that all treatment plans were reviewed and updated at least every 60 days.
Client #2 was admitted on March 17, 2020 and still active at the time of the inspection. A treatment plan update was completed on October 5, 2020 and an update was due no later than December 5, 2020 however an update was not completed until January 8, 2021.
Client #5 was admitted on January 9, 2020 and was discharged on December 14, 2020. A treatment plan update was created on May 29, 2020 and an update was due not later than July 29, 2020 however an update was not completed until October 28, 2020.
Client #7 was admitted on April 28, 2020 and was discharged on August 8, 2020. A treatment plan update was completed on May 12, 2020 and an update was due no later no later than July 12, 2020 however an update was not completed until August 4, 2020.
These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
The Director of Outpatient Services will oversee that all program staff are re-trained on treatment plan timeframes during a team meeting on 4/5/21. The office manager will be responsible for ongoing compliance and will track the completion of treatment plans for all clients. The office manager will oversee that clinical staff are re-educated as needed to review and update treatment plans at least every 60 days. |