INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 22, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Warren General Hospital 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 25, 2007.
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Plan of Correction
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704.1-704.2(a) LICENSURE Staffing Compliance Plan
CHAPTER 704. STAFFING REQUIREMENTS FOR DRUG AND ALCOHOL TREATMENT ACTIVITIES
704.1. Scope.
This chapter applies to staff persons employed by drug and alcohol treatment facilities which are licensed or approved under Chapters 157, 709 and 711 (relating to drug and alcohol services; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility) with the exception of staff persons employed in intake, evaluation and referral facilities as delineated in Chapter 709, Subchapter D (relating to standards for intake, evaluation and referral activities) and Chapter 711, Subchapter C (relating to standards for intake, evaluation and referral activities). Staff persons shall possess the qualifications set forth in this chapter and shall also participate in training as required in this chapter.
704.2. Compliance plan.
(a) The project's governing body shall approve a written compliance plan to insure that the staff persons affected by this chapter meet the appropriate educational and experiential qualifications and receive training as stipulated in this chapter.
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Observations
Based on a review of the hospital detoxification procedure manual on August 22, 2007, documentation for the hospital board meeting minutes for the period of September 2007 through August 2007 demonstrated that the facility failed to provide documentation of governing body approval of the staffing requirements for drug and alcohol treatment activities.
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Plan of Correction
As required by section 704.2, the Governing Body approved the written Compliance Plan at the October 25, 2006, board meeting and documented such approval in the minutes and on a form signed by the board President. The Project was able to produce for the surveyor a copy of the meeting minutes, but was unable to produce the form signed by the President. A new statement documenting the governing body's approval of the Compliance Plan will be obtained and signed by the President of the governing body during the October 2007, board meeting. The Project Director will ensure that such approval is obtained and maintained on site. |
704.11(a)(3) LICENSURE Training Feedback
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:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of the hospitals detoxification procedure manual, staff development program procedures, staff training files and staff personnel files on August 22, 2007 the hospital failed to collect feedback on completed training for the July 2006 through June 2007 training year in two of two employee files reviewed. File review number 1 and file review number 6 did not document the feedback collection information .
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Plan of Correction
The Project misinterpreted the breadth of the feedback required by section 704.11(a)(3). Beginning with the next training course, all personnel will complete a written feedback survey every time he/she attends a course. The next scheduled training for staff is to occur on October 23, 2007. The Project Director will ensure that all staff complete the feedback survey and the Director will maintain a copy of the feedback for use during the annual training evaluation. |
704.11(a)(4) LICENSURE Evaluation of Overall Plan
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:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a review of the hospital's staff development manual, detoxification procedure manual and board meeting minutes for the period of September 2006 through August 2007, the organization failed to complete an annual evaluation for the July 2006 through June 2007 training year.
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Plan of Correction
The annual evaluation for the 2006 fiscal year shall be completed by 9/24/2007. Thereafter, the annual evaluation shall occur within 30 days of the end of the fiscal year. The fiscal year ends on June 30 of each year. For the annual evaluation, the Project Director will evaluate the overall training plan and will determine the extent to which the plan addressed the identified training needs. The Project Director shall maintain documentation of the annual evaluation. |
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 staff development train ing files and personnel files on August 22, 2007 the hospital failed to to provide documentation of a minimum of 6 hours of HIV/AIDS in four of six of the files reviewed. File review numbers 1,2, 3, and four.
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Plan of Correction
·The Project did not achieve compliance with the communicable disease training requirements due to difficulties in coordinating course and staff availability. However, the Project Director will ensure that appropriate staff receives this education, regardless of staffing difficulties. The Project Director has scheduled the staff to receive this education on October 23, 2007. In the future, all new staff will comply with the education requirements within the time period allowed by section 704.11(c)(1). |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of the project/facility director personnel file and staff development training file on August 22, 2007, the hospital failed to provide twelve hours of training for the director during the July 2006 through June 2007 training year.
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Plan of Correction
The Project Director did not complete the training required by section 704.11(d)(2), due to scheduling conflicts. However, the Project Director understands the importance of this requirement and will complete the training required by section 704.11(d)(2). The Project Director is scheduled to obtain 6 hours of training on October 23, 2007, and 6 hours of training on November 30, 2007. |
157.23 (b) LICENSURE Patient records.
157.22 Patient records.
(b) Patient records shall be kept confidential in accordance with applicable Federal drug and alcohol regulations and the confidentiality requirements in 4 Pa. Code 255.4 and 255.5 (relating to UDCS: confidentiality and access to information and projects and coordinating bodies: disclosure of client-oriented information).
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Observations
Based on a review of two of two patient records reviewed on August 22, 2007, client record numbers 2 and 3, the hospital failed to obtain an authorization to release patient related information to managed care in client record number 3 and for Medicaid in client record number 2.
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Plan of Correction
The Project believed that the consent to treat language signed by the patient permitted the Project to disclose patient information to the patient's insurance provider for the purposes of receiving authorization for payment. The Project is firmly committed to complying with the confidentiality protections for its patients. This deficiency was immediately corrected and for all future patients, the Project Director will ensure that the patient completes an authorization to disclose specific information to the insurance provider. The Project remedied this issue on August 24, 2007, and a formal in-service was provided on September 13, 2007. |