Observations
Based on the review of personnel records, the facility failed to document that staff persons received a minimum of 6 hours of HIV/AIDS and/or at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum in two of two personnel records.
The findings include:
Five personnel records were reviewed on August 4, 2015. Two records reviewed required documentation of the HIV/AIDS and STD/TB training. There was no documentation of the training in personnel records # 1 and 2.
Employee # 1 was hired as the project director on January 8, 2013. The HIV/AIDS and STD/TB training was due to be completed no later than January 8, 2015. The facility failed to provide documentation of HIV/AIDS and TB/STD training.
Employee # 2 was hired as the facility director on January 8, 2013. The STD/TB training was due to be completed no later than January 8, 2015. The facility failed to provide documentation of the STD/TB training.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
4 hours of TB/STD/Hepatitis training was completed on August 11, 2015 by both employees found out of training compliance. The next available Basic HIV training that will be held within a 50 mile radius will be scheduled for the employee found out of compliance with the required 6 hour minimum HIV/AIDS training.
Individualized training plans for all employees will be used to list and track all training requirements and the Office Coordinator will be responsible for monitoring these plans to ensure all requirements are being met. This correction was instated August 5, 2015
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Observations
Based on a review of client records, the facility failed to document a consent to release information form that adhered to 42 CFR Part 2 Subpart C Section 2.31 (a)(8) & (c)(3) in six of six client records.
The findings include:
42 CFR Part 2 Subpart C Section 2.31 (a)(8) States the following:
A statement that the consent is subject to revocation at any time except to the extent that the program or person which is to make the disclosure has already acted in reliance on it. Acting in reliance includes the provision of treatment services in reliance on a valid consent to disclose information.
42 CFR Part 2 Subpart C Section 2.31 (c)(3) States the following:
A disclosure may not be made on the basis of a consent which:
(1) Has expired;
(2) On its face substantially fails to conform to any of the requirements set forth in paragraph (a) of this section;
(3) Is known to have been revoked;
Six client records were reviewed on August 4, 2015 for documentation of informed and voluntary consents to release information. Consent to release information forms in client records # 1, 2, 3, 4, 5 and 6 did not adhere to 42 CFR Part 2 Subpart C Section 2.31 (a)(8) and 42 CFR Part 2 Subpart C Section 2.31 (c)(3). Client records # 1, 2, 3, 4, 5 and 6 contained consent to release information forms that stated the revocation of the release needed to be in writing. Additionally the consent to release information forms contained "release to" and "obtain from" language.
Client # 1 was admitted on April 13, 2015 and discharged on July 29, 2015. A consent to release information form to an attorney, signed by the client on April 13, 2015, required that the revocation of the release needed to be in writing. The consent also, contained "release to" and "obtain from" language.
Client # 2 was admitted on July 1, 2015 and discharged on July 31, 2015. A consent to release information form to a government agency, signed by the client on June 25, 2015, required that the revocation of the release needed to be in writing. The consent also, contained "release to" and "obtain from" language. A consent to release information form to a third party payer, signed by the client on June 25, 2015, required that the revocation of the release needed to be in writing. The consent also, contained "release to" and "obtain from" language.
Client # 3 was admitted on March 10, 2015 and discharged on July 9, 2015. A consent to release information form to a government agency, signed by the client on March 10, 2015, required that the revocation of the release needed to be in writing. The consent also, contained "release to" and "obtain from" language.
Client # 4 was admitted on May 19, 2015. A consent to release information form to a government agency, signed by the client on May 14, 2015, required that the revocation of the release needed to be in writing. The consent also, contained "release to" and "obtain from" language. A consent to release information form to a third party payer, signed by the client on May 14, 2015, required that the revocation of the release needed to be in writing. The consent also, contained "release to" and "obtain from" language.
Client # 5 was admitted on July 6, 2015. A consent to release information form to a medical agency, signed by the client on June 16, 2015, required that the revocation of the release needed to be in writing. The consent also, contained "release to" and "obtain from" language. A consent to release information form to a third party payer, signed by the client on June 16, 2015, required that the revocation of the release needed to be in writing. The consent also, contained "release to" and "obtain from" language.
Client # 6 was admitted on June 8, 2015. A consent to release information form to a government agency, signed by the client on June 8, 2015, required that the revocation of the release needed to be in writing. The consent also, contained "release to" and "obtain from" language. A consent to release information form to a third party payer, signed by the client on June 8, 2015, required that the revocation of the release needed to be in writing. The consent also, contained "release to" and "obtain from" language.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
"Obtain from" language was omitted from the Release of Information disclosure and in the same disclosure in regards to revoking the release of information, "in writing" was omitted so that release of information could be revoked verbally as well. The office coordinator was responsible for editing/correcting this document and and will ensure this document was updated in all locations it is generated from including original file on the shared drive which all staff access it from and within the software where it is uploaded. Office coordinator will destroy any old paper copies. Clinical supervisor will monitor that the new form is being utilized in the monthly chart reviews. It was corrected by August 19, 2015 |
Observations
Based on a review of client records, the facility failed to include the type and frequency of treatment and rehabilitation services in two of four client records.
The findings include:
Six client records were reviewed on August 4, 2015. Four records were reviewed for comprehensive treatment plans. Two client records, # 1 and 3, lacked documentation of the type and /or frequency of treatment and rehabilitation services on the client's treatment plan.
Client #1 was admitted on April 13, 2015 and discharged on July 29, 2015. The treatment plan, completed on May 22, 2015, did not document the type and frequency of treatment and rehabilitation services.
Client # 3 was admitted on March 10, 2015 and discharged on July 9, 2015. The treatment plan, completed on April 2, 2015, did not document the type of treatment and rehabilitation services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All counselors were notified that type and frequency of treatment will be included in each client?s treatment plan. Every counselor will be responsible for adding this information to treatment plan and the Clinical Supervisor will oversee the charts for accuracy. This correction was already instated as of August 4, 2015 |