INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on January 20-21, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Berks Counseling Center, 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:
|
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 records, the facility failed to provide documentation of HIV/AIDS training in one of sixteen personnel records reviewed. Additionally, the facility failed to ensure that counselors complete mandatory communicable disease training within the the first year of employment in one of sixteen personnel records reviewed. The findings include:Sixteen personnel records were reviewed on January 20-21, 2016 for documentation of HIV/AIDS and TB/STD training. The facility did not provide documentation of the required HIV/AIDS training in personnel record # 15. The facility also failed to ensure that counselors complete the mandatory communicable disease training within the first year of employment in personnel record # 15. Employee # 15, a counselor, was hired on March 17, 2014. HIV/AIDS training was due to be completed no later than March 17, 2015. The facility failed to provide documentation of completed HIV/AIDS training as of the date of this inspection. Additionally, the employee completed TB/STD training on June 3, 2015. This training was due to be completed no later than March 17, 2015. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
All supervisors will schedule new staff for HIV/AIDS training within 6 months of employment to ensure that the training is completed before the end of the first year of employment. |
705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
|
Observations
Based on a physical plant inspection the facility failed to ensure all fire extinguishers are inspected and approved annually.The findings include:A physical plant inspection was conducted on 1/21/16. All of the facility's fire extinguishers, nine in total, were tagged with an inspection date of December 2014. The findings were discussed with staff during the licensing process.
|
Plan of Correction
Clinical Director of Drug and Alcohol Services will coordinate with office manager to ensure that all fire extinguishers are inspected and approved for the current year by the end of February of each year. Inspections were scheduled by the previous building owner in December and current building owner schedules them in January or February. If inspections are not completed when required, the office manager will notify the building manager.Building management was contacted at the time of the licensing inspection and again on 2/23/16 asking for a date for the fire extinguishers to be inspected. No reponse has been received as of yet. Projected completion of the inspection is March 31, 2016. |
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:
|
Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent in two of five client records reviewed. The findings include:Five client records requiring informed and voluntary consent to release information forms were reviewed on 1/21/16. The facility failed to obtain an informed and voluntary consent which identified the specific information to be disclosed in client record # 1. Additionally, the facility exceeded the limitations imposed in 4 Pa. Code, Subsection 255.5(b) as it pertains to the information authorized to be released per an informed and voluntary consent to release information form in client record # 2. Client # 1 was admitted into treatment on 8/28/15 and was still active at the time of the inspection. A consent to release for probation/parole, signed and dated on 8/28/15, failed to specify the purpose of the release. Client # 2 was admitted into treatment on 8/19/15 and was still active at the time of the inspection. A consent to release for probation, signed and dated on 8/19/15, allowed for the release of the client's discharge summaries, psychiatric evaluations, and medical records. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Supervisory staff will conduct trainings on consents for all staff who are involved in client care and complete consents.This training will be conducted by the end of March 2016 in all departments. We already instituted a specific release for probation that has the 5 areas allowable for release to probation. The staff person for Client #2 used the incorrect consent. Client #1 and Client #2 are no longer active at the facility. Supervisory staff conduct quarterly chart audits and will review all consents in the selected charts for compliance. If any consents are found to be non-compliant, the client's therapist will do a new consent with the correct information at the client's next scheduled session. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation in one of five client records reviewed. The findings include:Five client records requiring documentation of a psychosocial evaluation were reviewed on 1/21/16. A psychosocial evaluation was not documented in client record # 5. Client # 5 was admitted into treatment on 5/20/15 and was discharged on 10/2/15. A psychosocial evaluation was not documented in the client's record. The finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Clinical supervisors will review each client chart upon completion of the intake process to ensure that psychosocial evaluations are completed.If the psychosocial evaluation has not been completed, the counselor will be required to complete it within 7 days of the intake. Clinical supervisors will review at the end of the 7 day period. If the psychosocial has not yet been completed, the supervisor will proceed with that agency disciplinary process. |
709.93(a) 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:
|
Observations
Based on the review of client records, the facility failed to ensure that post-treatment follow-up contact with discharged clients was documented in two of five client records reviewed. The findings include: Two client records requiring documentation of follow-up contact with discharged clients were reviewed on 1/21/16. The facility failed to document follow-up contact in client records # 3 and 5.Client # 3 was admitted into treatment on 4/17/15 and was discharged on 10/14/15. The facility failed to document post-treatment follow-up contact with the client, as of the date of this inspection. Client # 5 was admitted into treatment on 5/20/15 and was discharged on 10/2/15. The facility failed to document post-treatment follow-up contact with the client, as of the date of this inspection. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Clinical supervisors instituted a new process to ensure timely completion of post-treatment follow up. This process started February 1, 2016. Upon receipt of discharge documentation, the program assistant for medical records calculates the 30 days and makes follow up calls on or prior to the date. Responsibility for oversight of this process falls under the Compliance Director. |