INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 16, 2017 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Casa De Consejeria Drug and Alcohol Counseling Program, 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)(3) & (4) LICENSURE Training types and amounts
704.11. Staff development program.
(c) General training requirements.
(3) At least one-half of all training in this section shall be provided by trainers not directly employed by the project unless the project employs staff persons specifically to provide training for its organization and staff.
(4) An individual who holds more than one position in a facility shall meet the training requirement hours set forth for the individual's primary position. Subject areas shall be selected according to the individual's training plan. Primary position is defined as that position for which an individual was hired.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report form, which was completed on 05/01/2017, and a review of 8 personnel records, the facility failed to ensure at least one-half of all training was provided by trainers not directly employed by the project in 1 employee record. Employee #5 was hired as a counselor assistant on 11/02/2015. The employee was required to complete 40 hours of training from 11/02/2015 to 11/02/2016; however, only 12 of the 40 training hours were provided by trainers not directly employed by the project.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In order to ensure the proper amount of hours are provided to counselor assistants by outside trainers not directly employed by the project, the clinical supervisor along with the facility director will follow the staff roster and create ticklers every month to check and follow-up with staff training plans and requirements. They will make sure that all counselor assistants are also complying with appropriate subject matter trainings and hours. If counselors do not comply they will be subject to our internal disciplinary process and potentially suspended. This action will be completed on an ongoing basis and will be supervised by project director on a monthly basis as a safety net for the continuance of the process.
At this time, the counselor mentioned is no longer employed due to her inability to comply with set requirements. |
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 a review of eight personnel files, the facility failed to ensure that the file for employee #1, who was hired as the project director on 10/30/15, contained any documentation of an annual written individual performance evaluation.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project director, who is also the executive director, will be evaluated on an annual basis by the board of directors. This current oversight will be included on the next board meeting, 6/27/17, and will be completed no later than 8/28/17 which is the immediate after the initial meeting. Moving forward the facility director will make arrangements with the president of the board to add this item on the meeting agenda least 90-days before the following evaluation is due in October of 2018 and so forth. |
709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
Based on a review of seven client records, the facility disclosed information without a client signed informed consent to release information form in client record # 1. Additionally, consent to release information forms in client record #'s 4 and 6 were missing required information.Client #1 was admitted on 08/30/2016 and was discharged on 02/10/2017. The record contained a letter to a referral source, dated 11/21/2016, which released drug screen analysis results; however, the consent form for the agency did not allow for the release of drug screen analysis results. Additionally, the record contained 14 urinalysis lab results from September 2016 through January 2017, which identified the client's presence in treatment; however, there was no documented consent to release information form or Qualified Service Organization Agreement in place for the lab prior to the disclosure. Client #4 was admitted on 08/10/2016 and was discharged on 03/08/2017. The record contained a consent to release information form, signed and dated on 08/10/2016, to the client's primary care physician, which did not include the name, agency, or organization to which information was to be released. Client #6 was admitted on 01/05/2017 and was still an active client at the time of inspection. The record contained a consent to release information form, signed and dated on 01/05/2017, to the client's primary care physician, which did not include the name, agency, or organization to which information was to be released.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor rechecked client file #6 and completed the release of information for the physician properly with the client within 24 hours from the conclusion of our licensing inspection/site visit. Currently, the release includes the PCP and practice's specific name to which any information, within he appropriate parameters, will be released to.
The clinical supervisor will hold an in- service training to 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 will be discussed. This will be completed by 7/31/17.
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.
QA/I monitor will insure that internal policies and procedures comply with both Federal and State confidentiality and reporting regulations by routinely auditing all program records. Corrective action and follow-up will be made to insure the appropriate disclosure of client information in service delivery.
Examples of QA/I monitoring activities are as follows:
· Monitor for documentation that clients are informed and understand their rights to confidentiality.
· Monitor to insure that there is a current, written informed release on file whenever information is disclosed to and from the treatment facility.
· Monitor to insure that the written release is time limited, content specific, signed and witnessed.
· Monitor for family and SP (special persons) inclusion.
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709.30 (1) 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.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on a review of seven client records, client record # 3 lacked documentation verifying written acknowledgement by the client that they had been notified of the client rights.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It is the policy of the organization that all clients have the right of information regarding access to treatment, emergency procedures, confidentiality and complaints and grievances. All clinical staff that conduct intakes will be re-trained by the clinical supervisor on the intake process which includes discussing the client's rights and responsibilities and signing verifying the completion of this process with each client no later than 8/31/17.
The following information will also be discussed:
Procedure:
Following the explanation and signing of the client's rights by both the client and the intake worker, the client will be offered a copy. The original will be placed in the client's chart. The following client's rights will be discussed:
- The client's right to be respected and treated with dignity at all times while receiving services from Casa de Consejeria.
- The client's right to have their particular ethnic and cultural heritage respected, understood, and incorporated into the overall service planning process and delivery.
- The client's right to have as much emphasis placed on assessing and utilizing individual strengths as is usually placed on assessing deficits.
- The client's right to be viewed as having some knowledge about their own lives and personal history and some capacity to set useful life goals.
- The client's right to utilize their own power in making decisions affecting their futures.
- The client's right to recover from chemical dependency and receive the necessary education, treatment, and support in order to do so.
- The client's right to receive good medical, dental, and mental health care through referral.
- The client's right to engage in activities that will increase independence in living arrangements, vocational and educational pursuits, and social supports.
- The right to avoid unnecessary hospitalizations, incarcerations, and other time out of the community.
- The client's right to overcome isolation and to perceive as a whole person having biological, psychological, social and spiritual needs.
- The client's right to not be deprived of any civil right solely by reason of treatment.
- The client's right to not be discriminated against on the basis of age, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap, or religion.
- The client's right to refuse treatment.
- The client's right to confidentiality.
- The client's right to file a complaint and grievance
- The client's right to fully participate in the treatment planning process.
- The client's right to inspect their own records subject to the following limitation:
- The project director may temporarily remove portions of the record prior to inspection by the client if he/she determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented and kept on file.
- The client has the right to appeal a decision limiting access to their records to the project director.
- The client has the right to request the correction of inaccurate, irrelevant, outdated, or incomplete information in his records.
- The client has the right to submit rebuttal data or memorandum and have it included in the record.
The client can request to have an audience with the Executive Director/Program Director in order to request their inspection of their own record. Such request shall be in writing and he/she will specify their motives for such request.
The Executive Director/Program Director shall document the client's request in their clinical record.
The Executive Director/Program Director and Clinical Supervisor shall review client's clinical record prior to such inspection, to make sure there is no information that may be detrimental if presented to the client.
Then the client shall be called by any program support staff no later than two (2) days after the client's request being placed in order for the client inspect their own record at our facility.
The client may appeal a decision limiting access to their records, in writing to the Program Director. The client may request the correction of inaccurate, irrelevant, outdated or incomplete information in his records, by submitting request in writing to the Director. Client may submit, in writing, rebuttal data or memorandum and has it included in the record. Client will be requested to sign a statement of understanding on the Patient Rights documented. If the client refuses to sign the Bill of Rights form, the clinician will document the reason on the bank form provided. Casa de Consejeria will post a copy of the Bill of Rights form in the bulletin board of the reception area located on the first floor and also in the bulletin board of the second floor located between the Administrative and Executive Director's office.
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