INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on October 20, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Cora Services, Inc. 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 personnel records and the facility's Staffing Requirements Facility Summary Report, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training and/or at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in one of five personnel records reviewed. Employee # 5 was hired as the project director/facility director on February 12, 2020 and was due to have both the HIV/AIDS training and the TB/STD training no later than February 12, 2022. However, both trainings were not completed as of the date of the inspection. This is a repeat citation from the October 13, 2021 annual licensing renewal inspection. This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The Facility Director is now registered with an external training service and has signed up for all necessary DDAP required Facility Director trainings. The facility director will submit all completed training certificates to clinical supervisor who is responsible for training management by 2/28/23. The clinical supervisor will verify that the trainings have been completed. The clinical supervisor will also conduct quarterly reviews of training requirements for all staff to ensure compliance. |
704.11(c)(3) & (4) LICENSURE Training types and amounts
704.11. Staff development program.
(c) General training requirements.
(3) At least one-half of all training in this section shall be provided by trainers not directly employed by the project unless the project employs staff persons specifically to provide training for its organization and staff.
(4) An individual who holds more than one position in a facility shall meet the training requirement hours set forth for the individual's primary position. Subject areas shall be selected according to the individual's training plan. Primary position is defined as that position for which an individual was hired.
|
Observations
Based on a review of personnel records, the facility failed to ensure that at least one-half of all annual trainings shall be provided by trainers not directly employed by the project in one of three applicable personnel records reviewed.Employee # 5 was hired as the project director/facility director on February 12, 2020. The record documented 16.5 hours of training for the facility's July 1, 2021 through June 30, 2022 annual training year; however, all 16.5 hours of training were provided by internal facility staff.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
CORA has contracted with external training management systems. CORA also purchased multiple training libraries that are appropriate for CORA staff to remain compliant with professional licensure and training requirements of licensing and credentialing agencies.
The Facility Director is now registered and assigned a training profile with external training management systems and now has access to a vast training library to stay compliant with DDAP external training expectations.
The clinical supervisor will conduct quarterly reviews of training requirements for all staff, including the facility director, to ensure compliance for this upcoming fiscal year and all subsequent years.
|
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.
|
Observations
Based on a review of client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in seven of seven client records reviewed. In every client record reviewed, there was evidence of disclosures to the funding sources during each client's treatment episode; however, there were no consent to release information forms signed by the clients documented in the records prior to any of the disclosures.Client #3 was admitted on March 29, 2022 and was still active at the time of the inspection. There was a documentation of contact made with an outside medical center on June 13, 2022 and June 14, 2022; however, there was no client-signed release of information form documented in the record prior to the disclosures.This is a repeat citation from the October 13, 2021 annual licensing renewal inspection.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
A release of information to the funding source was added to the client intake packet in the electronic health record. Staff were made aware of the change and instructed on the use of the new release of information form. Staff will implement the new release of information form for all new clients moving forward.
Of the 7 files reviewed, 3 were active cases who were missing a consent to release information to the funding source. Counselors assigned to these cases will obtain a release of information to the funding source by 12/15/22. The clinical supervisor will review all files on 12/15/2022 to ensure that the new forms are completed. Four of the 7 files reviewed have been discharged from services and a new release form is unable to be completed. Additionally, the clinical supervisor will conduct monthly chart audits to ensure that the appropriate release of information form is completed.
For client #3, it was found that the staff member documented "verbal consent" for the disclosure, as the consent was obtained during a telehealth session. The assigned counselor will obtain a proper release of information form for the client's medical provider with written consent by 12/15/22. Staff were provided with additional training on the confidentiality policy and the completion of release of information documents. Additionally, staff were advised that verbal consent cannot be obtained for the purposes of releasing information. To obtain a physical signature in the event that a client cannot physically attend a session, staff will utilize Adobe to send client's an electronic release of information form. This change of procedure was reflected in new staff training documents. The clinical supervisor will conduct monthly chart audits to ensure that proper documentation procedures are followed.
|
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).
|
Observations
Based on a review of client records, the facility failed to document the dated signature of the client on a consent to release information form in one of seven client records reviewed. Client #3 was admitted on March 29, 2022 and was still active at the time of the inspection. There was documentation that the client had given a verbal consent for a release of information to the single county authority; however, there was no dated signature of the client included on the consent form.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Staff were provided with additional training on the confidentiality policy and the completion of release of information documents. Additionally, staff were advised that verbal consent cannot be obtained for the purposes of releasing information. To obtain a physical signature in the event that a client cannot physically attend a session, staff will utilize an electronic records management system to send client's an electronic release of information form. This change of procedure was reflected in new staff training documents. The clinical supervisor will conduct monthly chart audits to ensure that proper documentation procedures are followed. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
|
Observations
Based on a review of client records, the facility failed to ensure that a copy of a client consent form was offered to the client in seven of seven client records reviewed.In every client record reviewed, there was a consent to release information form to the single county authority; however, there was no documentation in each record that a copy of the consent form was offered to the client.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The clinical supervisor will revise the release of information form to the single county authority, to include documentation that a copy of the consent form was offered to the client. Staff were advised of the change. For all current clients, staff will offer a client copy of the consent form by 12/15/22. Clinical supervisor will conduct monthly chart audits to ensure compliance. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
|
Observations
Based on a review of client records, the facility failed to document a complete client record, which is to include follow-up information, in two of two applicable client records reviewed. Client # 6 was admitted on January 26, 2022 and was discharged on June 30, 2022. There was no follow-up information documented in the record as of the date of the inspection. Client # 7 was admitted on May 20, 2022 and was discharged on July 14, 2022. There was no follow-up information documented in the record as of the date of the inspection. The findings were discussed with facility staff during the licensing process.
|
Plan of Correction
Staff were provided with additional training on department procedures for conducting follow-up after client discharge. Additionally, the clinical supervisor will review follow-up data monthly to ensure that follow-up is conducted.
The facility Director also created a Monthly Client Chart Review form that will be used by the Program Administrator to audit client charts monthly to ensure compliance with DDAP Policy.
|