INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted onMarch 17, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Casa De Consejeria Drug and Alcohol Counseling Program, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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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 ensure that staff persons and/or volunteers received 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 as per the regulatory requirements in one of six records reviewed.The findings include:Six personnel records were reviewed on March 17, 2014. Two of the six was reviewed for the mandatory HIV/AIDS and TB/STD training, # 4 and 5. Employee # 4, a counselor, was hired on January 3, 2013. Employee #4 was required to obtain 6 hours of HIV/AIDS training and 4 hours of TB/STD training by January 3, 2014. Employee #4 failed to document 6 hours of HIV/AIDS training as of the date of the licensing inspection. An interview with the project director on March 17, 2014 confirmed the findings.
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Plan of Correction
Clinical Supervisor will provide to the employee #4, (Counselor) 6 hours of HIV/AIDS training and 4 hours of TB/STD training based on the Department approved curriculum as per regulatory requirement.
Project Director will assess training need and it will be included on the employee individual training plan in order to be scheduled.
Project Director will meet Clinical Supervisor to provide the information in order to train the employee.
Project Director will review the training plan every year on this specific area to be in full compliance.
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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 personnel records and a interview with the Project Director, the facility failed to ensure that the facility had a sufficent number of staff trained in CPR and first aid.The findings include:Six personnel records were reviewed on March 17, 2014. During the licensing inspection, the Project Director informed this licensing inspector that the First Aid and CPR trainings were completed online. As of the date of the licensing inspection facilities have not been approved to utilize online trainings for First Aid and CPR.
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Plan of Correction
Project Director will make arrangements to send the 6 staff members to be trained on First Aid and CPR training by American Heart Association.
The Project Director will make sure that the registration for these trainings will not be done with online providers. The Project Director will inform the HR staff that only providers certified by the Department of Health can be utilize to obtain CPR and First Aid training. |
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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent in ten of ten records.The findings include:Ten client records were reviewed on March 17, 2014. The informed and voluntary consent forms are to document the purpose for the disclosures. The facility failed to document the purpose of the disclosure on the clients consent to release forms in records, #1, 2, 3, 4, 5, 6, 7, 8, 9 and 10.An interview with facility staff on March 17, 2014 confirmed the findings.
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Plan of Correction
Clinical Supervisor will provide training to the clinical staff in order to instruct them about the specific need of documenting the purpose of the disclosure on the clients consent to release forms. Clinical supervisor to review intakes for compliance to informed consent and address issues in supervision as needed. QA/I to regularly audit charts for compliance. Project director to email clinical staff, reinforcing reason for disclosure on release of information. |
709.93(a) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
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Observations
Based on a review of client records, the facility failed to have a complete record in two of ten records reviewed.The findings include:Ten client records were reviewed on March 17, 2014. Two of the ten client records were reviewed for discharge summaries, aftercare plans and follow-up documentation, #9 and 10.Client #9 was admitted on October 9, 2013 and discharged on January 7, 2014. The aftercare plan documented on January 17, 2014 failed to include the client's goals with time frames. The discharge summary also failed to include the client's reason for treatment. Lastly, there was no documentation of a follow-up documented as of the date of the licensing inspection.Client #10 was admitted on October 9, 2013 and discharged on December 24, 2013. As of the date of the licensing inspection there was no documentation of a follow-up in client #10's record.This was discussed and confirmed by facility staff on March 17, 2014.
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Plan of Correction
The Clinical Supervisor will provide training to clinical staff (counselors) about the following documentation necessary to complete the client's discharge summary.
Clinical supervisor and/or program director will review every discharge to insure that:
1. Every after care plan must include the client's goals with timeframes.
2. Every discharge summary must include
the client's reason for treatment.
3. The discharge summary should include the 7 or 30 days follow up letter after the date of the client's discharge.
QA/I will regularly audit discharges for compliance to discharge and aftercare policy. |