INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 20, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Stairways Behavioral Health Outpatient Drug and Alcohol Program 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(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
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Observations
Based on a review of the policy and procedure, the facility failed to include the time frames for completion in the comprehensive staff development program for the assessment of staff training needs, overall plan addressing the needs, a mechanism to collect feedback on completed training, and an annual evaluation of the overall training plan.This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Policy O00.72004 was modified to include language regarding identification of the training year, which occurs for each calendar year. Language was also added to identify that the assessment of training needs, plan for addressing needs, and evaluation of overall training plan will be completed within the first quarter of the following year. The Director of Risk Management, who oversees policy and procedure updates, completed the revision on 3/20/24, and the policy and procedure committee reviewed and approved the changes via email approval on 3/21/24. The facility director will ensure completion of the items within the time period indicated in the updated policy and procedure. |
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 facility failed to document what specific information could be disclosed on the consent to release form in one of seven records.Client #2 admitted on November 1, 2023 and discharged January 24, 2024. A release of information was signed on December 22, 2023 to an agency but did not indicate specific information to be disclosed. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
In response to the citation #2 referencing 709.28 (c) (2) Confidentiality; on 3/29/2024, the Program Director and prison supervisor met with the counselor who submitted the release of information that did not indicate the specific information to be disclosed, and reviewed correct completion of releases of information and the intended purposes of such releases. The Program Director reviewed other client charts from this counselor and found no additional errors in completion of the releases. On 4/2/2024, during the team staff meeting, supervisors reviewed with all clinical staff the correct procedure for completion of releases of information, and this will continue to be presented to staff members quarterly at team meetings and as part of new staff hiring/orientation. |