INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 24 - 25, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Community Counseling Center of Mercer County 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
The facility failed to provide documentation of TB/STD training in two of four personnel/training records. Staff #3 was hired 5-16-2016 and required to complete TB/STD training by 5-16-2017. As of the date of the inspection, the training was not completed.Staff #4 was promoted to counselor position on 11-18-2015 and required to complete TB/STD training by 11-18-2016. As of the date of the inspection, the training was not completed.These findings were reviewed with the facility staff.
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Plan of Correction
No training was offered within the given time frame which was accessible and therefore affordable. The two staff cited are scheduled for the next accessible training on March 15 of this year offered by the local SCA. They have already been registered.
The facility director will be responsible for assuring that the training is completed and the documentation placed in the chart. We will be in compliance by March 31, 2018.
It is the intention of the facility director to assure that new hires will be hired within the appropriate time frame identified by the regulation.Future budgeting will allow for attending training outside of the immediate area to assure they are acquired in a timely manner. |
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 from the client prior to disclosure in three of seven client records reviewed on January 24 - 25, 2018.Client #3 was admitted to treatment on June 19, 2017 and was discharged on September 21, 2017. The facility failed to document a release of information for the funding source. Client #4 was admitted to treatment on July 28, 2017 and was discharged on November 15, 2017. The facility failed to document a release of information for the funding source. Witness signatures are missing on four release of information forms signed on 7-28-2017.Client #6 was admitted to treatment on September 25, 2017. Witness signatures are missing on two release of information forms signed on 9-25-2017.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Two separate issues were identified regarding the consents to release information.
1) Consents were not obtained to release information to third party payers. These consents were completed by the billing staff. The individuals who complete these forms will receive an in service training on confidentiality and the necessity to complete consents for payment. Additionally, they will be sent to the next full confidentiality seminar offered by the local SCA during the next year. We will complete the in service training by March 15,2018. The Compliance Director will monitor the accurate completion of the billing consents weekly to assure mastery of the training. Ongoing monitoring will occur as needed.
2) The second issue identified was an absence of witness signatures on consents. This issue is related first to a computer issue of not saving a signature. However, this should have been identified by the person completing the form had they reviewed their work. Therefore, an in service training will be provided on confidentiality and the importance of assuring that the consent are completed correctly. This will be provided by March 15,2018. The Facility director will be responsible for providing the training and reviewing completion of consent on an ongoing basis to assure compliance.
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