INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 20, 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, Three Rivers Youth 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(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
The facility failed to document the counselor received at least 25 clock hours of training annually in one of one personnel records. Two personnel records were reviewed on March 20, 2019. One was reviewed as a counselor. The training hours were reviewed for the training year of July 1, 2017 to June 30, 2018. Employee # 2 was hired as a counselor on July 10, 2015 and required 25 hours of annual training. The personnel record documented only 2 completed training hours for the training year reviewed. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Employee #2 has completed 24 training hours for the 2018-19 year. The employee #2 is scheduled for Medication Assisted Treatment training on 4/25/19 and on the wait list for ASAM training.
The Project/Facility Director will follow-up with staff in regards to training plans during weekly supervisions to track target and make adjustments as needed.
The Project/Facility Director will monitor, recommend and schedule relevant trainings for staff to ensure training hours are met at the end of each year. |
709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
The facility failed to secure the client's record in one of seven client records. Seven client records were requested for review purposes during the March 20, 2019 licensing inspection. The facility produced only six client records. An interview with the facility director on March 20, 2019, revealed that one of the requested client records could not be located. An additional client record was requested so that a total number of 7 records were reviewed. The client record which could not be located was labled as client record #8. As of the end of the licensing inspection, client record, # 8 had not been located.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility located the client record # 8 on 3/22/19. The client record had been misfiled with the discharged treatment records in our secured file room as per staff disclosure.
The Project/Facility Director will offer a refresher on confidentiality, HIPAA and client record storage for treatment staff. The Project/Facility Director will monitor and review client records on a monthly basis to ensure security and accessibility. |
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
The project failed to document an informed and voluntary consent from the client in one of seven client records.Seven client records were reviewed on March 20, 2019. Seven records required documentation of consents. Client record # 3 was missing a consent to release of information for the third party funder. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project/Facility Director will follow-up with staff during weekly supervisions to discuss the importance of the informed and voluntary consent forms and verification.
The treatment staff will complete with every client, a consent to release information for the third party funder during their initial visit.
The Project/Facility Director will review and monitor client records on a monthly basis to ensure compliance of consents forms. |
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
The facility failed to document written acknowledgement that the client was informed of the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records in five of seven records reviewed. Seven client records were reviewed on March 20, 2019. Seven records required documentation of the client rights. Client records # 1, 2, 3, 5 and 6 did not document that the client was informed of the right. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The treatment staff and client reviewed
and signed updated client rights forms for 3 of the active records as of 4/19/19.
The treatment staff will complete updated client rights with every client during their initial visit.
The Director/Facility will review and monitor client records on a monthly basis to ensure accuracy and compliance with client rights. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
The facility failed to review and update the treatment and rehabilitation plan in four of six client records. Seven client records were reviewed on March 20, 2019. Six required treatment plan updates. Client records # 1, 2, 5 and 6 did not document updates within the required time frame. Client # 1 had an update due to be completed by August 21, 2018. There was no update documented as of the time of the clients discharge on September 14, 2018. Client # 2 had an update due to be completed by December 5, 2018. There was no update documented as of the time of the clients discharge on December 17, 2018. Client # 5, had an update due to be completed by November 28, 2018. The documented update was completed on January 28, 2019. Client # 6 had an update due to be completed by February 17, 2019. There was no update documented as of the time of the inspection on March 20, 2019. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facility/Director will review during weekly supervisions the importance of treatment plan updates and procedures if clients are not present.
The Treatment staff will complete treatment plan and updates with clients as scheduled based on agency protocol. If clients are not present for the update, the staff will complete and make adjustment as client becomes available.
The Director/Facility will review and monitor client records on a monthly basis to ensure accuracy and compliance with treatment planning and updates. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
The facility failed to document case consultation notes in three of three client records. Seven client records were reviewed on March 20, 2019. Three records required documentation of case consultation notes. Per facility policy, case consults are to be completed every three months. Client record # 4 was admitted on August 8, 2018 and was still an active client at the time of the inspection. Case consultation notes were to be completed by November 8, 2018. There was no documentation of case consultation notes in the record.Client record # 5 was admitted on July 18, 2018 and was still an active client at the time of the inspection. Case consultation notes were to be completed by October 18, 2018. There was no documentation of case consultation notes in the record.Client record # 6 was admitted on October 10, 2018 and was still an active client at the time of the inspection. Case consultation notes were to be completed by January 10, 2018. There was no documentation of case consultation notes in the record.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Treatment staff completed case consultations for all three of the active cases (Client #4, #5, #6) as of 4/19/19.
The Project/Facility Director will follow up with staff during weekly supervision to review and discuss any needed case consultations and to ensure timely completion based on agency protocols.
The Director/Facility will review and monitor client records on a monthly basis to ensure timeliness and compliance with case consultations. |