INITIAL COMMENTS
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This report is a result of an on-site licensure renewal conducted on August 31, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Caron Outpatient Services, LLC. 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 five personnel files on August 31, 2021, the facility failed to ensure that all counselors were trained in HIV/AIDS and TB/STD within the first year of employment and all other staff within the first two years.Staff #2 was hired on April 8, 2019 as the Project Director and is still current in that position. Staff #2 did not have documentation of six hours of mandatory HIV/AIDS training or four hours of mandatory TB/STD training. Staff #3 was hired on June 15, 2020 as the Facility Director and Clinical Supervisor and is still current in those positions. Staff #3 did not have documentation of four hours of mandatory TB/STD training. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director (Staff #2) is scheduled to attend six hours of HIV/AIDS training on 11/19/21. The Facility Director is scheduled to attend four hours of TB/STD training on 11/15/21.
The Clinical Supervisor is scheduled to attend four hours of TB/STD training on 11/15/21.
Copies of the trainings certificates will be forwarded to the Compliance Department to ensure completion of trainings. |
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
Based on a review of seven client records on August 31, 2021, the facility failed to document treatment plan updates within the regulatory timeframe in three out of seven client records reviewed. Client #5 was admitted on February 16, 2021 and was discharged on May 5, 2021. A treatment plan was completed on February 25, 2021, with the next update due no later than April 25, 2021; however, there were no other treatment plans documented in the record. Client #6 was admitted on March 9, 2021 and was discharged on May 21, 2021. A treatment plan was completed on March 11, 2021 with the next update due no later than May 11, 2021; however, there were no other treatment plans documented in the record. Client #7 was admitted on March 9, 2021 and was discharged on June 29, 2021. A treatment plan was completed on March 9, 2021, and the next update was due no later than May 9, 2021; however, the next update was not completed until May 11, 2021. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counseling staff will be re-educated on the requirements for completion of treatment plans and treatment plan updates within the regulatory timeframe. Re-education will occur by 10/15/21 and will be documented.
The Quality Department will conduct monthly medical record audits to ensure treatment plans are being completed as required. The result of the audits will be reviewed with the Clinical Supervisor and Facility Director. |