INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 14, 2007 through August 15, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Addiction Medicine and Health Advocate, 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 and a plan of correction is due on September 14, 2007.
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Plan of Correction
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of employee records it was determined that the facility failed to document the 25 annual training hours required for two of two counselor records reviewed, #5 and 6.
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Plan of Correction
One of the two employees is in graduate school and we initially neglected to show the reviewer his transcripts in order to count his classwork toward his training hours. Once we presented the documentation, we were under the impression that this satisfied the requirement for this employee. Both employees, as well as all other employees, will have a training plan for this training year to ensure that they have the required 25 hours. The Staff Development Coordintaor will be responsible for making sure the required hours are satisfied. |
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 and consent forms it was determined that the facility failed to comply with Commonwealth law at 71 P. S. Subsection 1690.112 which states that a minor be treated as if he has reached the age of majority and federal regulations at 42 CFR Part 2, Subpart B, Subsection 2.14(b) which directs that in such states, only the minor can consent to the release of information. The consent forms in ten of ten client records reviewed included a signature line for a parent or guardian.
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Plan of Correction
We will revise our release of information form by removing the signature line for a parent or guardian. The new version of the form will be presented to the staff and the the old forms will be destroyed. The Clinical Coordinator will be responsible for revising the form and distribution to staff. |
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 shall 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 it was determined that the facility failed to comply with state confidentiality laws. The written consent to release information forms found in the client records reviewed listed specific information to be released to probation, CBH (Community Behavioral Health), BHSI (Behavioral Health Services Incorporated) and the Philadelphia Department of Human Services which exceeded he limitations imposed by 4 Pa Code subsection 255.5(b) in ten of ten client records reviewed, #1, 2, 3, 4, 5, 6, 7, 8, 9 and 10.
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Plan of Correction
AMHA, in accordance with 4 Pa. subsection 255.5 (b), will restrict patient information to only the 5 items identified. There will be an in-service staff taining to reinforce the importance of adherring to 4 Pa. subsection 255.5. We will monitor adherence via AMHA's internal Quality Improvement project which includes random chart reviews. The Clinical Coordinator will be responsible for the training and supervision of staff. |