INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 18, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, SPHS Behavioral Health 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)(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 personnel records, the facility failed to ensure staff persons received a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training in one of three personnel records.
The findings include:
Seven personnel records were reviewed on February 18, 2016. Three personnel records were reviewed for documentation of HIV/AIDS and tuberculosis, sexually transmitted diseases (TB/STD) and other health related topics training. The facility failed to ensure employee # 7 received a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD training.
Employee # 7 was hired as a counselor on October 1, 2014. HIV/AIDS and TB/STD training was due to completed no later than October 1, 2015. There was no documentation of HIV/AIDS and TB/STD training in personnel record # 7, as of February 18, 2016.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will review with supervisor the policy and procedure of ensuring that all staff require the mandatory trainings to meet state regulations. Employee number 7 will be scheduled to attend the 6 hours of HIV/AIDS and 4 hours of TB/STD training. This will occur no later than 6/30/16. The Clinical supervisor will ensure that this staff and any future staff attend mandatory trainings in the appropriate time frames. |
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, the facility failed to obtain a written, informed and voluntary consent from the client prior to the disclosure of information contained in the client record in one of ten client records.
The findings include:
Ten client records were reviewed on February 18, 2016. Ten client records were required to include documentation of written, informed and voluntary consents from the client. The facility failed to obtain a written, informed and voluntary consent from the client prior to disclosing information contained in the client record in record # 10.
Client # 10 was admitted into treatment on November 2, 2015 and discharged on February 4, 2016. The client's name and progress update was faxed to a judge on February 4, 2016. There was no documentation of a written consent to release information to this judge in client record # 10, as of February 18, 2016.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A mandatory staff meeting will be held with all staff to review regulations and guidelines when completing consents to release information. The clinical supervisor will hold the staff meeting. In addition, The staff member who was responsible for chart 10 will obtain proper consents for the client if it is appropriate. To assure staff members are improving in this area internal chart reviews and supervision will take place by the Clinical Supervisor. This will occur no later than 3/31/16. |