INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 10, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, A1-Assist Behavioral Health Care Center, 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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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
The facility failed to ensure that employee #1, who was hired as the Chief Executive Officer on January 15, 2018, received an annual training plan for the current year based on a review of eight personnel records.The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Standard in non-compliance: 704.11(b)(1) LICENSURE
Individual training plan.:
704.11. Staff development program. (b) Individual training plan.
In an effort to correct standard 704.11 (b) (1), and to make certain, compliance is maintained.
Immediately following the Survey, the Chief Behavioral Healthcare officer discussed the findings of the site visit. The CEO was made aware of his responsibility to work with the Chairman of the Board to Develop an annual training plan that was inline with Standard 704.11 (b)(1).
The CEO's Developmental Plan has been completed for this current year, and will be updated in accordance with Standards annually.
Monitoring of compliance:
Credentialing Manager will monitor annually based on the appointed date of renewal.
Quality Assurance Manager will monitor bi-annually to ensure compliance.
Corrective Action Plan: Completed
Monitoring: On-going
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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.
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Observations
The facility failed to obtain an informed and voluntary consent to release information form prior to the disclosure of information in one of ten patient records reviewed.Patient #2 was admitted into the outpatient level of care on December 19, 2017 and was still active at the time of the inspection. There was a consent to the funding source signed December 19, 2017 and expired on June 19, 2018. There was no updated consent to release form documented in the client's record. There was evidence of billing to the funding source from the date of expiration to the date of inspection. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Plan of Correction:
Standard in Noncompliance
709.28 (c) Confidentiality
In an effort to comply with regulation 709.28, the written findings from the September 10, 2018, were discussed with all management staff during and immediately following the exit interview. In addition, the Director of BHS and clinical Coordinators held a joint clinical supervision session with the Counselor of Patient #2 to review all regulations regarding Confidentiality{ Informed and voluntary consent to release information and the important of making certain that all consents are current. To avoid a repeat of such an infraction, during the September's general staff meeting Standard 709.28 and the agency's Confidentiality policy and procedures supportive of Standard 709.28 was reviewed with all staff and a workflow was put in place for the QA team to review general consent forms such as: funding source, lab companies and emergency contacts to make certain they are current. In addition, workflows were reiterate with the Counselors and Correspondence Control Clerk to make certain all consent are current prior to the release of any information. Finally, an all staff Confidentiality Training is currently being negotiated with an approved DDAP trainer to occur within the next 90 days, as a refresher for existing staff and new hires.
Informed and voluntary consent forms will be randomly audited weekly for compliance by the Quality Control Clerks and Client Service Coordinator to ensure compliance during registration. A random audit of each therapist caseload will be conducted periodically by the Clinical Coordinator to ensure that standard 709.28 is being followed properly.
Audit reports will be reviewed by the Quality Assurance Manager corrective action will be implemented immediately if needed and reported to the Leadership Team monthly.
Correction Time: Correction Completed Monitoring On-going
Additional Training: Completed on/or before December 21, 2018. |