INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 15, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Warren General Hospital 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 training records and an interview with the facility director and counselor, the facility failed to provide documentation of HIV/AIDS and of TB/STD training in three of six personnel records, as required by regulation.
The findings include:
Six personnel records were reviewed on June 15, 2011. Six personnel records were required to have documentation of HIV/AIDS and of TB/STD training. Per regulation, staff persons shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD training. Counselors and counselor assistants shall complete the training within the first year of employment and all other staff shall complete the training with the first 2 years of employment. The facility did not provide documentation of HIV/AIDS and/or of TB/STD training in personnel training records # 4, 5 and 6.
Employee # 4 was hired on February 5, 2007. HIV/AIDS training was due to be completed no later than February 5, 2009. The facility failed to provide documentation of HIV/AIDS training on June 15, 2011.
Employee # 5 was hired on June 23, 2005. HIV/AIDS and TB/STD training was due to be completed no later than June 23, 2007. The facility failed to provide documentation of HIV/AIDS and TB/STD training on June 15, 2011.
Employee # 6 was hired on July 21, 2004. TB/STD training was due to be completed no later than July 21, 2006. The facility failed to provide documentation of TB/STD training on June 15, 2011.
An interview with the facility director and counselor on June 15, 2011 at 1:10 P.M. confirmed the HIV/AIDS and TB/STD training had not been completed for the above listed personnel.
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Plan of Correction
L 0067 HIV/AIDS and TB/STD Training
Responsible staff: Program Manager
The Program Manager will identify Department approved curriculum for required trainings by July 30, 2011.
All staff who have not completed required trainings within the appropriate timeframe will complete the trainings by September 15, 2011. The required trainings will be incorporated into the annual training schedule for all new employees.
Date: September 15, 2011
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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 on the review of personnel records and an interview with the counselor, the facility failed to document that each counselor completed at least 25 clock hours of training annually in one of one personnel record.
The findings include:
Six personnel records were reviewed on June 15, 2011. One personnel record was reviewed as a counselor. There was no documentation of 25 clock hours of training annually for the training year July 1, 2009 to June 30, 2010, for personnel record # 3.
Personnel # 3 had 18. 5 hours of training documented for the training year July 1, 2009 to June 30, 2010.
An interview with the counselor on June 15, 2010 at 1:10 P.M. confirmed she had only 18.5 hours of training for the training year July 1, 2009 to June 30, 2010.
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Plan of Correction
L 0083 Counselor Training Hours
Responsible staff: Program Manager
The Program Manager and Counselor will review the training plans quarterly to ensure completion of required training in a timely manner. Available trainings will be discussed for appropriateness. During the training year July 1, 2010 to June 30, 2011, routine reviews occurred and the Counselor completed 27 hours of training.
On July 8, 2011 the Program Manager and Counselor reviewed the Counselor's 2011-2012 training plan. The required number of training hours are scheduled to occur within the first quarter of the training year.
Date: July 8, 2011
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709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records and an interview with the counselor, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, in one of one client records.
The findings include:
Four client records were reviewed on June 15, 2011. One client record was required to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, in client record # 4.
Client # 4 was admitted into treatment on May 5, 2011 and was involuntarily terminated from the project on May 9, 2011. There was no documentation of written notification to the client at the time of the licensing inspection, on June 15, 2011
The counselor was interviewed on June 15, 2011 at approximately 1:20 P.M.. The counselor confirmed that the client had not received written notification of the decision to involuntarily terminate the client's treatment at the project
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Plan of Correction
L 0333 ? Notice of Termination: Reason
Responsible staff: Program Manager
A written Notice of Termination that includes the reason for involuntary termination will be developed by July 30, 2011. The form will be developed by the Program Manager and approved by the Medical Director. If a situation occurs prior to the approval of the form, a written notice, including the reason for involuntary termination as well as the documentation of client's decision to request reconsideration or declination of reconsideration, will be typed and a copy given to the client.
All staff will receive education regarding the written Notice of Termination by August 15, 2011.
100% of involuntarily terminated client charts will be reviewed for compliance for six months.
Date: August 15, 2011
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709.33(b) LICENSURE Notification of Termination
709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records and an interview with the counselor, the facility failed to notify the client of the opportunity to request reconsideration of a decision terminating treatment in one of one client record.
The findings include:
Four client records were reviewed on June 15, 2011. One client record required that the client be provided an opportunity to request reconsideration of a decision terminating treatment. There was no documentation of this requirement in client record # 4.
Client # 4 was admitted into treatment on May 5, 2011 and was involuntarily terminated from the project on May 9, 2011. There was no documentation the the client was provided an opportunity to request reconsideration of a decision terminating treatment on June 15, 2011
The counselor was interviewed on June 15, 2011 at approximately 1:20 P.M.. The counselor confirmed that the client had not been provided an opportunity to request reconsideration of a decision terminating treatment.
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Plan of Correction
L 0335 Notice of Termination: Reconsideration
Responsible staff: Program Manager
A written Notice of Termination will be developed by July 30, 2011. The notice will include the documentation of the client's decision to request reconsideration or declination of reconsideration. If a situation occurs prior to the approval of the form, a written notice, including the reason for involuntary termination as well as the documentation of client's decision to request reconsideration or declination of reconsideration, will be typed and a copy given to the client.
All staff will receive education regarding the written Notice of Termination by August 15, 2011.
100% of involuntarily terminated client charts will be reviewed for compliance for six months.
Date: August 15, 2011
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