INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 5-6, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Catholic Charities and Adoption 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:
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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
The facility failed to ensure that staff received the required HIV/AIDS and STD/TB training in one of one personnel record.
Four personnel records were reviewed on March 5-6, 2019. One personnel record, # 4, was reviewed for the required training.
Employee # 4 was hired as office manager on November 20, 1970. There was no documentation provided that she had completed the required HIV/AIDS and STD/TB trainings as of the date of this inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The staff member who was not up-to-date on HIV/AIDS and STD/TB training completed the required hours of training within the week following our site visit. The documentation of her completed training is recorded in her personnel file and will be available at our next site review.
The facility director verified that this course was, in fact, completed as required.
The facility director will monitor all staff training requirements each year to ensure that all required training has been fulfilled.
The facility director will monitor new employees' training to ensure that required trainings are fulfilled within the expected time frame. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
The facility failed to ensure that at least one person certified in CPR was onsite during the project's hours of operation.
Four personnel records were reviewed on March 5-6, 2019. There was no current CPR certification documented in the records. There was no documentation provided that any of the staff was currently certified in CPR.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Action 1: The personnel file for the worker who was current with CPR training but did not have his current card on file has been updated to reflect his current ACTIVE status.
Action 2: The facility director attended CPR/First Aid training through the local Red Cross office on 3/13/2019. As such, he is now also on ACTIVE status re: certification and a copy of his certificate is on file as well.
Action 3: The 2nd D&A worker has completed his on-line portion of CPR training and his "hands on" training is scheduled for later this month.
These actions will ensure that an employee who is CPR-certified will always be present in the building.
The facility director will ensure that all new employees will receive CPR training within the first year of employment.
The facility director will annually monitor staff certifications to ensure that any employee with an impending certification end date will complete follow-up re-certification prior to the current certification expiring.
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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
The facility failed to obtain an informed consent from the client in two of seven client records.
Seven client records were reviewed on March 5-6, 2019. Seven records required documentation of an informed consent. Client records # 1 and 5 were missing documentation of consents.
Client # 1 was missing a consent to release information to the third party payor.
Client # 5 was missing consents for the third party payor and a government agency. A letter was sent to the government agency on December 18, 2018.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facility director has met with both D&A workers to review the agency policy on obtaining Informed Consent signatures from clients at their initial session.
The facility director specifically discussed with workers the need to obtain Consent for any information released to outside sources, including the county D&A office - our referral source
Effective 3/18/19, the facility director will monitor weekly the Informed Consent documentation to ensure that it is being completed as expected. |
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.
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Observations
The facility failed to document that a copy of the consent was offered to the client in four of seven client records.
Seven client records were reviewed on March 5-6, 2019. Seven records were reviewed for consents. Client records # 1, 3, 5 and 6 did not document that the client had been offered a copy of the consent.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Action: The facility director met with the worker who failed repeatedly to ensure that the paperwork regarding Client consents was thoroughly and accurately completed.
The facility director reinforced the requirement that all clients be offered a copy of their Consent AND that this offer MUST be documented by checking the appropriate box on the Consent form.
Effectively 3/18/2019, the facility director will weekly monitor for accurate and thoroughly completed Client Consents. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
The facility failed to document a psychosocial evaluation in two of seven client records.
Seven client records were reviewed on March 5-6, 2019. Seven required documentation of a psychosocial evaluation. In client records # 1 and 3, there was no documentation that the psychosocial evaluation had been completed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Action: The facility director met with the worker who repeatedly failed to complete biopsychosocial reports. It is the written policy of our agency to complete such documentation in a timely manner.
Effective 3/18/2019, the faciity director will monitor case files to ensure that each and every file contains a biopsychosocial report. |
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
The facility failed to document that the treatment and rehabilitation plans were reviewed and updated at least every 60 days in two of seven client records.
Seven client records were reviewed on March 5-6, 2019. Seven required treatment plan updates. Client records # 3 and 7 did not document required updates.
Client # 3 had a treatment plan completed on November 9, 2018. An update was due to be completed by January 9, 2019. The update was completed on February 8, 2019.
Client # 7 had a treatment plan completed on August 23, 2018. An update was due to be completed by October 23, 2018. There was no update documented. Client was discharged on November 1, 2018.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Action: The facility director met with both D&A workers to once again stress the importance of obtaining all necessary and required signatures for client treatment plans in a timely manner. The agency expectations were reviewed.
Effective 3/18/2019, the facility director will weekly monitor case files to ensure that treatment plans are being updated and reviewed with/by clients in a timely manner. |
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.
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Observations
The facility failed to document follow up information in two of two client records.
Seven client records were reviewed on March 5-6, 2019. Two records were reviewed for follow up information. Client records # 6 and 7 were missing follow up information.
Client # 6 was discharged on November 30, 2018. Follow up was to be completed by February 28, 2019. There was no follow up documented.
Client # 7 was discharged on November 1, 2018. Follow up was to be completed by February 1, 2019. There was no follow up documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Action: Effective 3/18/2019, the agency has changed its procedure for sending out follow-up surveys. The facility director and the office manager have re-worked the computer process for the sending of the follow-ups and the proper recording of such procedures.
The facility director also discussed with workers the need to accurately and thoroughly document ALL contacts (or ATTEMPTED contacts) with clients.
The facility director also discussed with workers the need to close out files in a more timely manner.
The facility director will monitor each month the reports of follow up letters to ensure that each client who terminates services with our program will be contacted for follow-up. |