INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on March 2, 2015 and March 3, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Family Service Association of Bucks County 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 and training records, the facility failed to provide documentation of HIV/AIDS and TB/STD training in one of seven records reviewed
The findings include:
Seven personnel records which required documentation of mandatory communicable disease training were reviewed on 3/2/2015. The facility failed to ensure that HIV/AIDS and TB/STD training was completed within the first year of employment for employee # 21.
Employee # 21 was hired 6/11/2013 as a counselor. This employee was required to obtain six hours of HIV/AIDS and 4 hours of TB/STD training by 6/11/2014. Employee # 21 completed HIV/AIDS training on 12/15/2014 and TB/STD training on 6/30/2014.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
It is the policy of Family Service Association to require all clinical and support staff involved in the Behavioral Health Program to receive the 6 hour HIV and 4 hour STD/TB trainings as outlined in 704.11 Mandatory Communicable Disease Training.
Staff sign off on this expectation in orientation.
The Human Resource Coordinator tracks training attendance and notifies the assigned Clinical Supervisor of training needed. The Human Resource Coordinator will include the Director of Clinical Services in HIV and STD/TB training notifications as part of the corrective action plan as of 3/23/15.
The Director of Clinical Services sent a memo to the Behavioral Health Program clinical and support staff to remind them of the need for these trainings on 3/23/15.
Clinical Supervisors are addressing this training requirement with all clinical and support staff who are new to the program and who will require the training.
As of March 4, 2015, the Director of Clinical Services is on the email contact list for the Bucks County Department of Health, who is offering the training on 5/8/15. The Director has sent this date to all Clinical Supervisors and the Office Manager along with clinical and support staff to notify them of this upcoming training on 2 occasions and will forward registration information to all clinical and support staff when it is received.
Family Service will implement a new process in which the Clinical Supervisors and Office Manager will track and send a list of individuals on their respective teams who require this training to the Director on the last work day of each month. Director of Clinical Services and Clinical Supervisors will review in Program Development Meetings which are held weekly to ensure follow up in training attendance. Records of training attendance are maintained in each employee file by the Human Resource Department staff.
The Director of Clinical Services has acquired contact information for the AIDS Activities Coordinating Office and HRSA website information in order to access other training options available. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
|
Observations
Based on a review of client records, the project failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plan in six of ten client records reviewed.
The findings include:
Ten client records were reviewed for counseling services on 3/2/2015 - 3/3/2015. The project failed to ensure that clients receive counseling services according to the client ' s individual treatment and rehabilitation plan in client records # 2, 3, 5, 6 and 9.
Client record # 2 contained a treatment plan dated 1/22/2015 that identified the counseling services to be provided as individual therapy sessions 1 time per week. There were no individual therapy sessions scheduled for the client the weeks of 2/15/2015 - 2/28/2015.
Client record # 3 contained treatment plans dated 9/25/2014 and 11/20/2014 that identified the counseling services to be provided as individual therapy sessions 1 time per week. There were no individual therapy sessions scheduled for the client the weeks of 11/9/2014 - 11/15/2014 and 11/23/2014 - 11/29/2014.
Client record # 5 contained a treatment plan dated 4/25/2014 that identified the counseling services to be provided as individual therapy sessions 1 time per week. There were no individual therapy sessions scheduled for the client the weeks of 5/11/2014 - 5/17/2014 and 5/25/2014 - 7/5/2014.
Client record # 6 contained a treatment plan dated 9/17/2014 that identified the counseling services to be provided as individual therapy sessions 1 time per week. There were no individual therapy sessions scheduled for the client the weeks of 10/12/2014 - 11/15/2014.
Client record # 9 contained treatment plans dated 12/16/2014 and 2/2/2015 that identified the counseling services to be provided as individual therapy sessions 1 time per week. There were no individual therapy sessions scheduled for the client the weeks of 12/28/2014 - 2/7/2015.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Family Service is committed to providing the highest quality services to the people we serve. Treatment Plans are to be done with the individual, outlining that person's goals and measurable objectives to attaining them as well as identifying frequency of attendance to sessions. It is often the expectation that an individual will attend weekly therapy sessions and then for whatever reason, cannot.
To address this, the Director of Clinical Service sent an email on 3/23/15 to all clinical staff informing them of our citation in this area and two ways to manage this: one, offer the client an alternate session whenever possible to maintain consistency with treatment plan frequency documented and document the individual's response in the client chart; and two, document that the clinician followed up with the client, the client's response and when the next planned session will be.
Clinical Supervisors have begun the process of reviewing the need to match frequency of sessions with what is stated in the treatment plan and the importance of following up with the client and documenting responses, with clinicians in individual supervision and will also discuss at the next group supervision on 4/24/15 and 4/27/15.
the therapist works with the individual to determine frequency of attendance to treatment and documetns this on the treatement plan. There is a drop down selection to denote frequency of sessions on the treatment plans. Currently the options are "weekly;" "biweekly;" "monthly;" "other." All initial/engagement treatment plans were revised on 3/23/15 to offer the option of noting sessions will be held twice per month. This option may be a little less confining and better meet and reflect some individuals' abilities to attend therapy.
The Director of Clinical Services will revise the Behavioral Health Program's internal chart review audit form to include a question specifically defined to measure if the session frequency matches what is indicated on the treatment plan and if there is documentation to support when the frequency does not match. This will begin in the next quarterly chart review scheduled for May 18, 2015. |