INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 5, 2009, January 6, 2009, and January 14, 2009, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pennsylvania Counseling Services - Reading Psychiatric 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 February 13, 2009.
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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
Based on a review of personnel records, the facility failed to document that all staff persons received a minimum of 6 hours HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum, within the timeframe required. Counselors and counselor assistants shall complete the training within the first year of employment.
Findings:
The facility failed to document that a counselor (employee #3), hired on June 6, 2007, received the required HIV/AIDS and TB/STD training within one year from the date of hire.
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Plan of Correction
It was documented during the licensing visit that Employee #3 attended a 12 hour DOH HIV/AIDS training in April 1996. Employee #3 is currently registered to attend TB/STD training. The Quality Improvement Department will be closely monitoring the training needs of staff and will conduct individual meetings with staff as needed to support completion of mandatory trainings. Due to the difficulty in finding trainings, PCS has designated an administrative person to research training availability and notify each of our offices. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on a review of the facility ' s policy and procedure manual, the facility failed to document a written policy/procedure that shall comply with 4 Pa. Code 255.5
The findings include:
The facility's policy and procedure manual was reviewed on January 5, 2009 and January 6, 2009. The facility's policy regarding confidentiality of client identity and records included language allowing the facility to disclose information to the parent or guardian of a minor without the minor's consent.
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Plan of Correction
The Quality Improvement Department will revise the confidentiality policy to comply with all federal and state confidentiality laws. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to document the individual treatment and rehabilitation plan as per facility policy. The facility policy indicates the individual treatment and rehabilitation plan will be completed no later than 30 days following the completion of the psychosocial evaluation.
Findings:
Fourteen client records were reviewed on January 14, 2009. Documentation of the client's individual treatment and rehabilitation plan was required in ten client records. The facility failed to document the individual treatment and rehabilitation plan, as per facility policy, in four of ten client records, #2, 4, 5, 7.
In client record #2, the individual treatment and rehabilitation plan was due by June 8, 2008, but was not documented as completed until June 23, 2008.
In client record #4, the individual treatment and rehabilitation plan was due by June 7, 2008, but was not documented as completed until June 16, 2008.
In client record #5, the individual treatment and rehabilitation plan was due by June 30, 2008, but was not documented as completed until July 2, 2008.
In client record #7, the individual treatment and rehabilitation plan was due by June 8, 2008, but was not documented as completed until June 18, 2008.
Additionally, the facility failed to document an individual treatment and rehabilitation plan for client #8.
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Plan of Correction
The Quality Improvment Department and Facility Director met with clinical staff at staff meeting and reviewed treatment plan development. Staff were encouraged to develop the treatment plan with the client in a session prior to the due date. The QI Department will monitor ongoing compliance via random chart reviews. |