INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 11, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Perry Human Services 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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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on a review of four personnel records, the facility failed to hire a facility director that met the experience requirements for the position.
?Employee #1 was hired as a facility director on October 12, 2021 and was still current in that position. Employee #1 did not meet the experience requirements for the position.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Going forward, the facility director, at that time, and the Board of Directors will be responsible for ensuring that persons hired into positions meet both the educational and experience required by DDAP. Said individuals will adhere to the requirements set forth by DDAP. If the experience is questionable, said individuals will reach out to a DDAP representative directly for clarification. |
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
Based on a review of seven client records, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in two client records reviewed.
Client#2 was admitted on June 22, 2021 and was an active client as of the date of the inspection. A consent to release form was signed and dated on January 13, 2021, to the funding source that allowed for the release of drug and alcohol evaluations and psychosocial evaluation.
Client#4 was admitted on April 23, 2021 and was an active client as of the date of the inspection. A consent to release form was signed and dated on March 5, 2021, to the funding source that allowed for the release of drug and alcohol evaluations and psychosocial evaluation.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Additional confidentiality training will be completed with all clinical staff members regarding consents, focusing on specific releases of information and what information can be released. This will be documented in treatment meeting notes completed by the executive director. Updated the release form for all clients to ensure correct information on the SCA release. Director will continue to review all releases during chart audits monthly to ensure compliance. |