INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 23, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Holcomb Associates, 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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709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
The facility failed to ensure that all personnel records contained documentation of an annual written individual performance evaluation for the 2018 review year in four of nine employee records reviewed.
Employee # 3 was hired as a clinical supervisor on October 5, 2017.
Employee # 4 was hired as a clinical supervisor on June 17, 2013.
Employee # 7 was hired as a counselor on July 27, 2017.
Employee # 8 was hired as a counselor on August 3, 2017.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Coordinator will complete all evaluations annually. Clinical Coordinator will also ensure that all evaluations are completed and submit these to Human Resources. HR staff will review that all staff have completed performance evaluations within their HR files. |
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.
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Observations
The facility failed to obtain an informed and voluntary consent to release information form prior to the disclosure of information in two of seven client records.
Client # 1 was admitted on June 29, 2018 and was active at the time of the inspection. There was documentation of the facility billing the funding source; however, the last consent form to the funding source expired on January 5, 2019 and there was no active consent form on file prior to the disclosure of information.
Client # 3 was admitted on October 12, 2018. There was documentation of the facility billing the funding source; however, the last consent form to the funding source expired on April 14, 2019 and there was no active consent form on file prior to the disclosure of information.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
A spreadsheet will continue to be used to track expirations dates for consents. Each month the Coordinator will review with the treatment team, Clinical Support Services, and Administrative Case Manager which consents are coming up to expire in that given month.
Clinical Coordinator will check each to ensure timely and thorough completion of consent renewals.
Clinical Coordinator did review this feedback with her staff on 4/25/19. Clinical Coordinator also followed up with CSS Coordinator on 5/8/19 in regards to CSS completing consents in their entirety, and using the resources available.
For Client #1, his funding source consents were updated on 4/30/19.
Client #3, is currently incarcerated, so updated consents cannot be completed at this time. Client is being discharged from the program. If client returns, appropriate consents will be obtained immediately.
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709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
The facility failed to include the specific information that was to be disclosed on a consent to release information form in one of seven client records.
Client # 1 was admitted on June 29, 2018 and was active at the time of the inspection. There was a consent to release information form to a family member signed and dated by the client on July 5, 2018; however, that consent form did not include the specific information to be disclosed.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Coordinator will follow up with CSS Coordinator to offer an internal training to CSS of how to complete consents. All staff were reminded to utilize visual aids and resources that have been created that outline how to complete a consent in its entirety.
Clinical Coordinator will continue to review completed consents, and provide feedback to staff as needed. Coordinator will check each to ensure timely and thorough completion of consent renewals.
Clinical Coordinator did review this feedback with her staff on 4/25/19. Clinical Coordinator also followed up with CSS Coordinator on 5/8/19 in regards to CSS completing consents in their entirety, and using the resources available.
On 4/30/19, consents for Client #1 were completed for a family member (emergency contact), and the consent form includes the specific information to be disclosed. |
709.28 (c) (5) 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:
(5) Dated signature of witness.
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Observations
The facility failed to document the dated witness signature on a consent to release information form in one of seven client records.
Client # 1 was admitted to on June 29, 2018 and was active at the time of the inspection. There was a consent to release information form to a probation officer signed and dated by the client on July 5, 2018; however, that consent form did not include a dated witness signature.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Coordinator will follow up with CSS Coordinator to offer an internal training to CSS of how to complete consents. All staff were reminded to utilize visual aids and resources that have been created that outline how to complete a consent in its entirety.
Clinical Coordinator will continue to review completed consents, and provide feedback to staff as needed. Coordinator will check each to ensure timely and thorough completion of consent renewals.
Clinical Coordinator did review this feedback with her staff on 4/25/19. Clinical Coordinator also followed up with CSS Coordinator on 5/8/19 in regards to CSS completing consents in their entirety, and using the resources available.
On 4/30/19, consents for Client #1 were completed. The consent for PO includes the specific information to be disclosed, and has a dated witness signature.
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