INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 11, 2009 and February 12, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Trehab Center, 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 and a plan of correction is due on March 6, 2009.
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Plan of Correction
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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of staff development records and an interview with the clinical supervisor on February 12, 2009 the facility failed to provide CPR certification and first aid training to a sufficient number of staff.
The findings included:
Four staff development records and four personnel records were reviewed on February 12, 2009. Three of the four records, records # 1, 3 and 4, did not include verification of CPR and first aid training. The facility is open forty three hours a week. Staff trained in CPR and First Aid work thirty seven and one half hours a week. An interview with the clinical supervisor on February 12, 2009 provided verification that the program does not have sufficient staff trained to cover the 5 1/2 hours per week left open when trained staff leave for the day, or to cover those times when trained staff are not available, such as: vacation, sick or out-service training situations.
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Plan of Correction
Immediately following the onsite inspection on 2/11 and 2/12, 2 additional staff members at Trehab were signed up for the next available CPR/First Aid Class at Red Cross. Clinical Supervisor will ensure that these staff members attend this training and continue to renew there certification as applicable in the future. Clinical Supervisor ideally is working on all staff becoming CPR/First Aid certified in case there is staff turnover resulting in a insufficient number of staff with the appropriate CPR and First Aid Training. Clinical Supervisor will also continue to maintain her own CPR/First Aid Certification through The American Red Cross |
709.28(c)(3) 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 shall be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review of seven client records and an interview with the clinical supervisor, the project failed to obtain informed and voluntary consent from the clients for the release of client identifying information in four of seven client records.
The findings included:
Four of seven client records reviewed on February 12, 2009 did not have informed and voluntary consents to release information since the purpose of disclosure was not documented on those consents to release information. Nine of thirty consent to release information forms in the seven client records reviewed did not include the purpose of disclosure. Client records # 1, 3, 4 and 6 failed to document informed and voluntary consents.
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Plan of Correction
Clinical Supervisor met with all couseling staff immediately following the completion of the onsite inspection and reviewed the regulation pertaining to confidentialy and releases of information, particularly pertaining to disclosing the pupose of the consent. The Clinical Supervisor reiterated the importatnce of documenting informed and voluntary consent. Clinical Supervisor will audit 3-5 random charts on a monthly basis to ensure that this is being done at all times. |
709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
Based on a review of four active client records and an interview with the clinical supervisor on February 12, 2009 the facility failed to comply with 55 PA Code Part III relating to Medical Assistance reimbursement for services in two of four client records.
The findings include:
Two of four active client records reviewed on February 12, 2009 failed to comply with 55 PA Code Part III relating to Medical Assistance since treatment plans and treatment plan updates were not signed by the facility's medical director.
Client record # 1 - The client was admitted on November 13, 2009. The treatment plan was established on November 13, 2009 and the treatment plan update was documented on January 10, 2009. Neither were signed by the medical director.
Client record # 4 - The client was admitted on September 10, 2008. The treatment plan was established on September 10, 2008 and the treatment plan updates were documented on November 2008 and January 2009. Neither were signed by the medical director.
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Plan of Correction
Clinical Supervisor will contact our medical doctor this week and notify him of 55 PA Code Part III, and effective immediately, have him sign the treatment plans of all individuals who are funded through BHSI, in addition to those funded through Medical Assistance. Clinical Supervisor will audit 3-5 random charts on a monthly basis to ensure that this is being done. Client also met with staff immediately after the site visit on 2/11 and 2/12 to explain this plan of correction and the importance of our medical doctor signing the above mentioned treatment plans in order to remain compliant with 55 PA Code Part III. |