INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 5, 2009, January 6, 2009, and January 15, 2009, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pennsylvania Counseling Services - Gettysburg 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 February 13, 2009.
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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 document that all 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 using a Department approved curriculum, within the required timeframe. Counselors and counselor assistants shall complete the training within the first year of employment.
Findings:
The facility failed to document the required HIV/AIDS and TB/STD training for employee #3 within one
year from the date of hire. Employee #3 was hired as a counselor on August 15, 2007.
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Plan of Correction
Employee #3 is registered to attend both HIV/AIDS and TB/STD trainings. The Quality Improvement Department will be closely monitoring the training needs of staff and will conduct individual meetings with staff as needed to support completion of mandatory trainings. Due to the difficulty in finding trainings, PCS has designated an administrative person to research training availability and notify each of our offices. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on a review of the facility ' s policy and procedure manual, the facility failed to document a written policy/procedure that shall comply with 4 Pa. Code 255.5
The findings include:
The facility ' s policy and procedure manual was reviewed on January 5, 2009 and January 6, 2009. The facility ' s policy regarding confidentiality of client identity and records included language allowing the facility to disclose information to the parent or guardian of a minor without the minor ' s consent.
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Plan of Correction
The Quality Improvement Department will revise the confidentiality policy to comply with all federal and state confidentiality laws. |
709.93(a)(9) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to document an aftercare plan for each client record.
Findings:
Eleven client records were reviewed on January 15, 2009. Aftercare plans were required in six client records. The facility failed to document aftercare goals and action steps that were individualized to each client's needs or that were stated in measurable terms of measurable criteria in four of six client records, # 6, 8, 9, and 11.
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Plan of Correction
The Quality Improvement Department has revised the Aftercare Plan to include prompts to remind therapists to create individualized goals. The QI Department will also be re-educating clinical staff via staff meeting to develop individualized aftercare plans with personal/measurable goals and action steps. QI will then monitor on-going compliance through random chart reviews and re-educate staff as necessary. |