INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 18, 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, Persad 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:
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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 records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee's #5, #6, #7 and #8 received the minimum of 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #5 was hired as a counselor on June 18, 2018 and was due to have the TB/STD and other health related topics training no later than June 18, 2019. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
Employee #6 was hired as a counselor on January 3, 2018 and was due to have the TB/STD and other health related topics training no later than January 3, 2019. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
Employee #7 was hired as a counselor on February 20, 2018 and was due to have the TB/STD and other health related topics training no later than February 20, 2019. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
Employee #8 was hired as a direct support professional on November 16, 2016 and was due to have the TB/STD and other health related topics training no later than November 16, 2018. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Persad will identify a DDAP approved TB/STD trainer in the community that is comparable to DDPA's to ensure employee's receive this training in the required time frame. Employee #5 is scheduled for TB/STD on 10/3/19; Employee #6 is on a waitlist for the 10/3/19 TB/STD training; Employee #7 has been scheduled for TB/STD training on 10/3/19; Employee #8 has been scheduled for TB/STD training on 11/1/19. It is expected that staff will be up to date with training requirements by 12/1/19.
The clinical supervisor will monitor training plans of all employees. If at the 9 month (out of 12 months) mark an employee has not yet completed all of the required DDAP trainings, they will need to do so within the remaining the 3 months. |
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
Based on the review of personnel records and staff trainings, it was determined that the project failed to ensure that at least one person trained in CPR/First Aid is onsite during the project's hours of operation. All project employees were not CPR/First Aid Certified at the time of the inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Persad has identified a CPR/First Aid trainer who is going to train all Persad staff on 10/3/19. Going forward Persad will ensure that we have someone certified in CPR/First aid working at all times. We will ensure that all staff's certifications are up to date by offering this training on an annual basis. Both the Clinical Director and Clinical Supervisor will ensure that all Clinical staff have up-to-date certifications. |
705.28 (d) (2) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(2) Conduct fire drills during normal staffing conditions.
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Observations
Based on the review of the facilities fire drills log, it was determined that the facility failed to conduct fire drills during normal staffing conditions. Eight out of twelve fire drills did not have any participants therefore, evacuation times and exits used during the fire drill were not applicable.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Starting 10/1/19 Persad will conduct monthly fire during business hours. Drills which will be overseen by the Executive Director. The Executive Director will ensure full participation of employee's. |
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on the review of the facility policies and procedure manual, it was determined that the project director failed to prepare, annually update and sign a written manual delineating project policies and procedures. The facility s policies and procedures manual was last updated on July 18, 2017.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Persad will prepare, annually update and sign a written manual delineating project policies and procedures (completed by 11/1/19). The Clinical Director will be responsible for presenting the reviewed and updated manual to the Board of Directors annually (reviewed by 11/30/19). Board meetings occur once per month and so the next available time to review this material will be in November. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on the review of personnel records, the facility failed to document an annual written individual staff performance evaluation for employee #2.
Employee #2 was hired on November 16, 2016 and promoted on May 1, 2018. The annual staff performance evaluation was due no later than May 1, 2019. There was no annual staff performance evaluation documented at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director of Persad has put the following procedure in place: Starting in fiscal year 19-20, all Persad employee's will be reviewed annually no later than 10/31 of each year. This will ensure that performance evaluations are done consistently and within the required time frame. Employee #2 will have a completed performance evaluation by 10/31/19. The Executive Director will ensure that Employee #2's performance evaluation(s) are always up to date. |
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
Based on the review of client records, it was determined that the project failed to document that informed and voluntary consent was obtained for one out of seven client records reviewed.
Client # 6 was admitted on September 24, 2018 and was a current client at the time of inspection. Clinical staff corresponded with the client's employer via email but failed to obtain informed and voluntary consent to do so.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Persad Clinical Director and Clinical Supervisor will review procedures as they relate to release of information with the clinical staff to ensure that all consent forms are up to date (to be done during clinical staff meetings). We will continue to utilize quarterly chart audits to ensure that client consent forms are accurate and current. The therapist for client #6 will complete a new release of information with client if the need to release information is still valid. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the project failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in client record #'s 4, and 6.
Client #4 was admitted on January 22, 2019 and was an active client at the time of the inspection. An informed and voluntary consent to disclose information form was signed on January 22, 2019 to the client's probation officer that allowed for the release of treatment summaries and service dates.
Client #6 was admitted on September 24, 2019 and was an active client at the time of the inspection. There were email correspondences between the project and the client's employer. There was no informed and voluntary consent to disclose form signed, giving permission to disclose information to the client's employer and information provided in the emails was outside of the scope of what 4 Pa. Code 255.5 permitted employers to have as the client's progress in treatment was discussed.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Persad's Clinical Supervisor and Clinical Director will review confidentiality regulations as it pertains to drug and alcohol client's to all clinical staff on a monthly basis during clinical staff meetings (to begin 10/7/19). We will also create a unique release of information form to include the 5 pieces of information that can be released. The therapists for clients #4 & 6 will only provide information pertaining to the 5 pieces of information which can be released as per PA law. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on the review of client records and the client handbook, the project failed to fully notify clients of their rights. The project failed to document that clients would not be discriminated in the provision of services on the basis of "ethnicity, marital status and handicap" in seven out of seven client records reviewed.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
On 9/25/19 the Clinical Supervisor updated the client's rights section of our orientation packet, as well as, our non-discrimination policy, to include "creed, ethnicity, and marital status." (These were the only ones missing). |
709.30 (5) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Based on the review of client records and the client handbook, the project failed to fully notify clients of their rights. The project failed to document that clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their (client's) records in seven out of seven client records reviewed.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
On 9/26/19 the Clinical Supervisor updated our client's rights section of our orientation packet to include "clients have the right to request the correction of inaccurate, irrelevant, outdated, or incomplete information in their (client's) records." |
709.30 (6) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on the review of client records and the client handbook, the project failed to fully notify clients of their rights. The project failed to document that clients have the right to submit rebuttal data or memoranda to their own records.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
On 9/26/19 the Clinical Supervisor updated the client's rights section of our orientation packet to include "clients have the right to submit rebuttal data or memoranda to their own records." |
709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Based on the review of client records, it was determined that the facility failed to file a written unusual incident report with the Department within 3 business days following the notification of a client's death.
The facility was notified on March 6, 2019 that client #1 was deceased. The facility failed to file a written unusual incident report with the Department.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Persad Clinical Supervisor and Clinical Director will review policy and procedure around reporting of unusual incidents with all clinical staff during our upcoming clinical staff meeting (10/7/19). Clinical Supervisor will provide clinical staff with a list of reportable incidents so that everyone is aware. Clinical Supervisor will update policy/procedure around reporting of unusual incidents by 10/31/19. Clinical Staff will inform wither the Clinical Supervisor and/or Clinical Director when such an event occurs so that the appropriate actions can be taken to make sure that all necessary documentation is completed and submitted within 3 days of the incident. |