INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 29, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pennsylvania Counseling and Psychiatric 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 and a plan of correction is due on .
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Plan of Correction
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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 shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on a review of the facility ' s policy and procedure manual, the facility failed to document a written policy/procedure that shall comply with 4 Pa. Code 255.5
The findings include:
The facility ' s policy and procedure manual was reviewed on January 5, 2009 and January 6, 2009. The facility ' s policy regarding confidentiality of client identity and records included language allowing the facility to disclose information to the parent or guardian of a minor without the minor ' s consent.
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Plan of Correction
The Quality Improvement Department will revise the confidentiality policy to comply with all federal and state confidentiality laws. |
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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to obtain an accurate informed and voluntary consent from the client for the disclosure of information contained in the client record in two of four client records reviewed.
The findings include:
Six client records were reviewed on January 29, 2009. Informed and voluntary consents for the disclosure of information were required in four client records. The facility's consent forms included language that stated the client may revoke consent only in writing in client records #2 and 3. Clients may, in fact, revoke consent either verbally or in writing.
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Plan of Correction
PCS had previously revised all consents to include language that allows for verbal or written revocation and these consents are in use at all of our locations. The Quality Improvement Department will follow the recommendations of DOH licensing specialists and re-educate staff via staff meeting that if a consent is used that still contains the statement only allowing for written revocation that it is the staff's responsibility to error out "in writing" which would then allow for verbal revocation. The Quality Improvement Department will ensure through chart reviews that the releases are corrected in client records #2 and #3 and that all consents utilized allow for both verbal and written revocation. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to document complete aftercare plans in two of two client records.
The findings include:
Six client records were reviewed on January 29, 2009. Aftercare plans were required in two client records. The facility did not document aftercare goals that were individualized to each client's needs or that were stated in measurable terms in client records #5 and 6.
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Plan of Correction
The Quality Improvement Department has revised the Aftercare Plan to include prompts to remind therapists to create individualized goals. The QI Department will also be re-educating clinical staff via staff meeting to develop individualized aftercare plans with personal/measurable goals and action steps. QI will then monitor on-going compliance through random chart reviews and re-educate staff as necessary. |
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, the facility failed to ensure that all staff receive six hours of HIV/AIDS training and four hours of TB/STD training within the required time frame in one of two personnel records reviewed.
The findings include:
Five personnel records were reviewed on January 5, 2009 and January 6, 2009. Two personnel were required to have completed at least six hours of HIV/AIDS training and four hours of TB/STD training at the time of the inspection. Personnel record #5 was required to have had HIV/AIDS and TB/STD training on or before 6/27/08. Personnel record #5 was missing HIV/AIDS and TB/STD training.
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Plan of Correction
Personnel #5 is registered to attend both HIV/AIDS and TB/STD trainings. The Quality Improvement Department will be closely monitoring the training needs of staff and will conduct individual meetings with staff as needed to support completion of mandatory trainings. Due to the difficulty in finding trainings, PCS has designated an administrative person to research training availability and notify each of our offices. |