INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on May 3, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Colonial House Outpatient 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee #6 received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #6 was hired as a counselor assistant on October 7, 2021 and was still in this position at the time of the inspection. Employee # 6 was due to have the communicable disease trainings no later than October 7, 2022. HIV/AIDS training and the TB/STD training did not occur until March 2023 and April 2023.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Employee #6 is now up to date with required trainings, along with all other staff as submitted on SRFSR.
To prevent this from happening in the future, Human Resources Representative is now assessing training needs during Onboarding and completing training plans upon hire.
|
709.28 (c) 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.
|
Observations
Based on two of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in client records # 1, and # 2.
Client # 1 was admitted on January 25, 2023 and was still active at the time of the inspection. A consent to release form to a federal parole agency documented in the client record were provided to the client by the agency. There was no documentation of an informed and voluntary consent from the client for the disclosure of information to the parole agency from the facility.
Client # 2 was admitted on January 11, 2023 and was still active at the time of the inspection. A consent to release form to a federal parole agency documented in the client record were provided to the client by the agency. There was no documentation of an informed and voluntary consent from the client for the disclosure of information to the parole agency from the facility.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Executive Director created an agency consent to release form for the federal parole agency to be signed alongside the consent provided to the agency by the federal parole agency- as required per their treatment stipulations.
Active federal parole clients at the site were asked by Counselor #4 to sign the agency consent to release form for the parole agency.
Moving forward, all federal parole clients will sign both an agency federal parole consent and the consent provided by the federal parole agency upon intake.
Outpatient Services Supervisor will audit all active charts weekly and upon discharge to ensure compliance with completion of agency consent. |
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.
|
Observations
Based on one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the specific information disclosed.
Client # 6 was admitted on February 15, 2023 and discharged on March 24, 2023. An informed and voluntary consent from the client for the disclosure of information dated March 11, 2023 to medical assistance and two county agencies did not provide the specific information that was to be disclosed.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the April 25, 2022 annual licensing inspection.
|
Plan of Correction
Staff training provided by Executive Director in staff meetings on 05/11/2023 and 05/18/2023 regarding the completion of consents, specifically, specific information disclosed.
A corrective action was also issued to the employee.
Charts will be audited weekly by OP Services Supervisor to ensure compliance. |
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 must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
|
Observations
Based on one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the purpose of disclosure.
Client # 6 was admitted on February 15, 2023 and discharged on March 24, 2023. An informed and voluntary consent from the client for the disclosure of information dated March 11, 2023 to medical assistance and two county agencies did not provide the purpose of disclosure.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the April 25, 2022 annual licensing inspection.
|
Plan of Correction
Staff training provided by Executive Director in staff meetings on 05/11/2023 and 05/18/2023 regarding the completion of consents, specifically, purpose of disclosure.
A corrective action was also issued to the employee.
Charts will be audited weekly by OP Services Supervisor to ensure compliance. |