INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 7, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Rehab Management, Inc. 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 that all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in one of two applicable personnel records reviewed.
Employee # 4 was hired as a counselor on September 13, 2021 and was due to have the HIV/AIDS and TB/STD trainings no later than September 13, 2022. The HIV/AIDS training was not completed until January 30, 2023 and the TB/STD training was not completed until February 17, 2023.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Identified staff did complete training on January 30, 2023. Moving forward, clinical supervisor and executive director with the support of the clinical director and quality manager will ensure that TB/STD and HIV/AIDS trainings will be completed within DDAP regulation timeframe standards. New staff will review training requirements at time of new hire orientation and at least 1x/quarter. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document the dated signature of the client on a release of information form in one of seven client records reviewed.
Client # 2 was admitted on January 10, 2023 and was still active at the time of the inspection. The release of information form to the funding source was signed and dated by a witness on January 10, 2023, but the form did not include the dated signature of the client.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Supervisor met with clinician after exit interview to review active client needing updated ROI on 3/7/23 with expectation of completion by next date of service on 3/7/2023 (same day as inspection). Action completed. Moving forward, the supervisor will conduct random chart audits of each clinician at a rate of two charts per clinician monthly to randomly inspect that proper consent is obtained. Potential revisions of release of information in our electronic medical record are being explored by leadership in order to increase compliance. |