INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 10-12, 2018 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Cove Forge Behavioral Health System at Williamsburg 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 document that staff received the required HIV/AIDS and/or the tuberculosis, sexually transmitted diseases and other health related topics training, within the first 2 years of employment, in four of six personnel records reviewed on March 26-27 and April 10, 2018.Twenty seven personnel records were reviewed. Six required documentation of the trainings. Personnel records # 24, 25, 26 and 27 did not provide documentation of the required trainings. Employee # 24 was hired on August 23, 2015 as a care tech. There was no documentation, as of April 10, 2018, that the employee had completed the required HIV/AIDS and the tuberculosis, sexually transmitted diseases and other health related topics training. Employee # 25 was hired on February 8, 2016 as a driver. There was no documentation, as of April 10, 2018, that the employee had completed the required HIV/AIDS and the tuberculosis, sexually transmitted diseases and other health related topics training. Employee # 26 was hired on September 2, 2015 as a driver. There was no documentation, as of April 10, 2018, that the employee had completed the required tuberculosis, sexually transmitted diseases and other health related topics training. Employee # 27 was hired on February 13, 2000 as housekeeping. There was no documentation, as of April 10, 2018, that the employee had completed the required HIV/AIDS and the tuberculosis, sexually transmitted diseases and other health related topics training. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Staff #24, 25, 26 and 27 will attend HIV training on May 15, 2018. Staff #24, 25, 26 and 27 will attend STD/TB training on May 22, 2018.
Moving forward, to ensure compliance, quality management will keep a list of all new hires on a spreadsheet. The spreadsheet will be sent to department heads on a quarterly basis so they are aware of staff who have not yet completed these trainings.
Managers will be responsible for assuring their staff have these trainings in the appropriate timeframes.
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709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
The facility failed to notify the client, in writing of the decision to involuntarily terminate their treatment at the project in one of one client record reviewed on April 10-12, 2018. Client # 6 was involuntarily terminated on July 6, 2017. There was no documentation that the client was notified in writing of the decision. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director/Clinical Supervisor reviewed the process of Administrative Discharges in conjunction to the licensing standard with the Rehab/PHP Clinical staff during a meeting and in writing on 4/13/18.
Program Director/Clinical Supervisor reviewed the process of Administrative Discharges in conjunction to the licensing standard with the Detox Clinical Staff on 4/19/18 during a meeting and in writing.
All Clinical staff were re-educated on the Notification of Termination forms in the HCS system, our electronic medical record, and the documentation standards when a client refuses to sign a form.
The Program Director/ Clinical Supervisor will review all Administrative Discharges within the facility for 3 months. If at the end of 3 months it is found all charts are in compliance, random chart reviews will be conducted on a quarterly basis.
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715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
The facility failed to document a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to the administration of an agent in one of five records reviewed on April 10-12, 2018. Five clients were reviewed as Subutex clients. Client # 5 was administered the first dose on July 30, 2017. The face to face was documented on July 31, 2017. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO will remind the physicians of the regulation stating that a face to face history and physical will be completed on all opiate dependent patients prior to initiating a Buprenorphine protocol.
The Medical Records Coordinator will review 5 records per month for the next three months to ensure compliance. |