INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 30 - August 1, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Freedom Healthcare Services, LLC 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
Based on a review of personnel training records and the Staffing Requirements Facility Summary Report, the facility failed to provide documentation of communicable disease training in two of three personnel training records.
The findings include:
Ten personnel training records and the Staffing Requirements Facility Summary Report were reviewed on July 30, 2012. Three personnel training records were reviewed for documentation of communicable disease training. The facility failed to provide documentation of HIV/AIDS and TB/STD training in personnel training record # 10. The facility failed to document TB/STD training in personnel training record # 4.
Employee # 4 is a counselor and was hired on February 23, 2009. TB/STD training was due to be completed no later than February 23, 2010. The facility failed to provide documentation of TB/STD training for employee # 4.
Employee # 10 is support staff and was hired on August 18, 2009. HIV/AIDS and TB/STD training was due to be completed no later than August 18, 2011. The facility failed to provide documentation of HIV/AIDS and TB/STD training for employee # 10.
The project/facility director and clinical supervisor were interviewed throughout the licensing inspection and confirmed the findings.
This is a repeat citation from the March 1 - 2, 2011 and March 8 - 9, 2012 licensing inspections.
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Plan of Correction
Employees will be scheduled for HIV and STD as soon as possible. Clinical Supervisor will review trainings provided by local facilities weekly for available slots and monitor enrollment by employees found to be out of compliance. |
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 informed and voluntary consent from the client for the disclosure of information contained in the client record in two of three client records.
The findings include:
Eighteen client records were reviewed on July 31 - August 1, 2012. Three client records required documentation of a consent to release information to verify the client's insurance benefits. The facility accessed the Internet site of a funding entity to confirm the client's current insurance coverage. Prior to releasing client information to this funding entity, the facility failed to document an informed and voluntary consent from the client in client records # 2 and 4.
Client # 2 was admitted into treatment on June 4, 2012. The facility accessed the Internet site of a funding entity to confirm insurance coverage on June 4, 2012. The facility failed to obtain an informed and voluntary consent from client # 2.
Client # 4 was admitted into treatment on May 25, 2012. The facility accessed the Internet site of a funding entity to confirm insurance coverage on May 25, 2012. The facility failed to obtain an informed and voluntary consent from client # 4.
The clinical supervisor was interviewed throughout the licensing inspection and confirmed the findings.
This is a repeat citation from the March 1 - 2, 2011 and March 8 - 9, 2012 licensing inspections.
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Plan of Correction
These deficiencies were for patients admitted in May and June. When through chart reviews,clinical supervisor became aware of the deficiency, clinical supervisor retrained intaker worker and there were no deficiencies after that time. Clinical supervisor reminded intake worker and counselors of the correct way to complete consents again in staff meetings on August 6 and 13. Clinical supervisor will conduct monthly random chart reviews of new admissions to assure that procedure is being followed. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of the reason for involuntary termination of the client's treatment at the project, in one of one client records.
The findings include:
Eighteen client records were reviewed on July 31 - August 1, 2012. One client record pertained to an involuntary termination of the client's treatment. The facility failed to notify the client, in writing, of the reason for involuntary termination of the client's treatment at the project, in client record # 18.
Client # 18 was admitted into treatment on June 1, 2012 and was involuntarily terminated from the project on July 16, 2012. The client was notified, in writing, of the involuntary termination. However, this notification did not include the reason for the client's involuntary termination of treatment at the project.
The clinical supervisor was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
Clinical supervisor created a template letter for involuntary discharges. This letter includes a place to insert the reason for discharge. Clinical supervisor advised all counselors to use the letter in the staff meeting of August 13, 2012. Clinical supervisor reviews all discharges and will assure that all patients who are involuntarily discharged receive a letter explaining the reason and that a copy of the letter is retained in the chart. |