INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 9, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Casa de Consejeria y Salud Integral, 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of personnel records, the facility failed to ensure that clinical supervisors who have not functioned for 2 years as a supervisor in the provision of clinical services completed a Department-approved core curriculum in clinical supervision in one of one applicable personnel record reviewed. Employee #3 was hired as a clinical supervisor on September 7, 2021 and did not have at least 2 years of clinical supervision experience prior to being hired at the facility. There was no documentation of the clinical supervision core curriculum training on file at the time of the inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director will secure the necessary training to fulfill the less than 2 year supervisor experience requirement for the clinical supervisor. The facility director will send weekly emails to DDAP TMS and the other approved sites to check for availability until securing a spot. We are hoping to secure a spot by 8/31/2022.
In the future when a clinical supervisor is hired with less than 2 years of supervisory experience the facility director will send weekly emails to all state approved sites for supervisory training until securing a spot with in the first six months of employment of that supervisor.
The project director will follow up with facility director monthly during supervision meetings to ensure we are doing everything in our power to secure a training spot for any new hires and our current clinical supervisor. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on an administrative review, the facility failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities. This is a repeat citation from the annual licensing inspection conducted on May 17, 2021.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director has contacted an independent public accountant who will have our 2020 financial audit completed by the date indicated above. The Executive Director will make sure to secure the commencement of future audits no later than May 31 through an engagement letter and completed by June 30. |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency or organization to whom the disclosure was to be made on release of information forms in one of seven client records reviewed. Client #4 was admitted on June 2, 2021 and was discharged on August 9, 2021. The release of information form to an emergency contact was signed by the client and witness on June 2, 2021. However, the form did not document the name of the person to whom the disclosure was to be made.This is a repeat citation from the annual licensing inspection conducted on May 17, 2021.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor will hold an in-service training to discuss timely revisions and checks of releases of information in order to prevent expiration, lapses of time while a client is active in our program, and appropriate completion of whom the release is for. The training will focus on including the specific name of individuals and not keep it general or blank. Active charts will be audited in order to rectify any ROIs out of compliance and active clients will sign a new ROI.
The in-service will also discuss essential information and forms which will facilitate compliance to general guidelines of client confidentiality framed by 4 Pa Code 255.5 regulations and 42 CFR Part 2, including the Health Insurance Portability and Accountability Act (HIPPA) The nature of the release and the circumstances by which the information may be released, the specific content and limited nature of the information to be disclosed, to whom specifically, the purpose of the disclosure, the method of releasing the information as well as the timeframes for the release, signature of client and witness, date of signatures and whether the client has received a copy. This will be completed by 7/15/22.
Clinical staff shall continue to attend recommended Department of Health training and provide documentation in areas such as confidentiality and client recordkeeping. This will be monitored by HR on an annual basis. |
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).
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Observations
Based on a review of client records, the facility failed to document a dated signature of the client on release of information forms in one of seven client records reviewed.Client #6 was admitted on February 19, 2021 and was discharged on December 22, 2021. There was a release of information form to another treatment provider signed by the client. However, the dated signature of the client was not documented on the form.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor and/or facility director will hold an in-service training to discuss timely revisions and checks of releases of information in order to prevent expiration, lapses of time while a client is active in our program, appropriate completion of whom the release is for, and client and witness signatures. The training will focus on including the correct signatures with dates for the clients and witnesses. Active charts will be audited in order to rectify any ROIs out of compliance and active clients will sign a new ROI.
The in-service will also discuss essential information and forms which will facilitate compliance to general guidelines of client confidentiality framed by 4 Pa Code 255.5 regulations and 42 CFR Part 2, including the Health Insurance Portability and Accountability Act (HIPPA) The nature of the release and the circumstances by which the information may be released, the specific content and limited nature of the information to be disclosed, to whom specifically, the purpose of the disclosure, the method of releasing the information as well as the timeframes for the release, signature of client and witness, date of signatures and whether the client has received a copy. This will be completed by 7/15/22.
Clinical staff shall continue to attend recommended Department of Health training and provide documentation in areas such as confidentiality and client recordkeeping. This will be monitored by HR on an annual basis. |
709.28 (c) (5) 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:
(5) Dated signature of witness.
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Observations
Based on a review of client records, the facility failed to document a dated signature of the witness on release of information forms in one of seven client records reviewed.Client #6 was admitted on February 19, 2021 and was discharged on December 22, 2021. There was a release of information form to another treatment provider signed by the witness. However, the dated signature of the witness was not documented on the form.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor and/or facility director will hold an in-service training to discuss timely revisions and checks of releases of information in order to prevent expiration, lapses of time while a client is active in our program, appropriate completion of whom the release is for, and client and witness signatures. The training will focus on including the correct signatures with dates for the clients and witnesses. Active charts will be audited in order to rectify any ROIs out of compliance and active clients will sign a new ROI.
The in-service will also discuss essential information and forms which will facilitate compliance to general guidelines of client confidentiality framed by 4 Pa Code 255.5 regulations and 42 CFR Part 2, including the Health Insurance Portability and Accountability Act (HIPPA) The nature of the release and the circumstances by which the information may be released, the specific content and limited nature of the information to be disclosed, to whom specifically, the purpose of the disclosure, the method of releasing the information as well as the timeframes for the release, signature of client and witness, date of signatures and whether the client has received a copy. This will be completed by 7/15/22.
Clinical staff shall continue to attend recommended Department of Health training and provide documentation in areas such as confidentiality and client recordkeeping. This will be monitored by HR on an annual basis. |