INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 30, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, WES Corporation, 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(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 and the Staffing Requirement Facility Summary Report, the facility failed to ensure all staff received at least 4 hours of tuberculosis, sexually transmitted diseases, and other health related topics training within regulatory time frame.
Employee #1 was hired as the project/facility director on November 1, 2019. The TB/STD training was due no later than November 1, 2021; however, there was no documentation that the training was completed as of the date of the inspection.
Employee #2 was hired as a counselor on January 25, 2016. The TB/STD training was due no later than January 25, 2017; however, there was no documentation that the training was completed as of the date of the inspection.
Employee #3 was hired as a case manager on December 22, 2020. The TB/STD training was due no later than December 22, 2022; however, there was no documentation that the training was completed as of the date of the inspection.
This is a repeat citation from the January 27, 2021 annual licensing renewal inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
All 3 staff cited will complete TB/STD training by 7/1/2023.
The Program Director shall review training status for each staff members during weekly program meetings.
To prevent recurrence, the Quality Management Director meetings will review training files of program staff on a quarterly basis to ensure compliance with training regulations.
The Quality Management Director and the Human Resources Director will be responsible for ensuring that the correction action is implemented.
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709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document the dated signature of the client on release of information forms in seven of seven client records reviewed.
Every release of information form in each client record reviewed failed to include the dated signature of the client.
This is a repeat citation from the January 27, 2021 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Program Staff will update all consents and release of information forms for each client to include a written signature by the client by 4/1/2023.
The program director shall review status of completed and signed consents and releases of information for each client during weekly program meetings.
To prevent recurrence, the Quality Management Director shall review client records on a quarterly basis to ensure that every consent and release of information contains a written signature from client. The Quality Management Director shall report findings to Program Director.
The Quality Management Director will be responsible for ensuring implementation of the correction. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to ensure that treatment and rehabilitation plans were reviewed and updated at least every 60 days in five of seven client records reviewed.
Client #1 was admitted October 27, 2022 and was active at the time of inspection. The individual treatment plan was completed on November 4, 2022 and the first update was due no later than January 4, 2023. However, the update was not completed until January 30, 2023.
Client #2 was admitted February 17, 2022 and was active at the time of inspection. A treatment plan update was completed on September 12, 2022 and the next update was due no later than November 12, 2022. However, the update was not completed at the time of inspection.
Client #3 was admitted June 9, 2022 and was active at the time of inspection. A treatment plan update was completed on September 7, 2022 and the next update was due no later than November 7, 2022. However, the update was not completed until December 27, 2022.
Client #4 was admitted February 28, 2022 and was discharged July 5, 2022. A treatment plan update was completed on April 25, 2022 and the next update was due no later than June 25, 2022. However, the update was not completed at the time of inspection.
Client# 5 was admitted April 7, 2022 and was discharged August 25, 2022. The individual treatment plan was completed on April 7, 2022 and the next update was due no later than June 7, 2022. However, the update was not completed until August 15, 2022.
This is a repeat citation from the January 28, 2021 and January 27, 2022 annual licensing renewal inspections.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Treatment plans for all clients will be updated by 4/1/2023.
Going forward, Program clinical staff shall complete updates of treatment and rehabilitation plans on a monthly basis with clients. If a client does not attend treatment before the monthly update, the clinical staff will continue to complete plans, stating why the client did not sign, until the client either returns to treatment or is discharged for not attending treatment.
Program clinical staff shall obtain written signatures from clients for each treatment plan that is completed with the client.
The program director shall review treatment plan updates for each client during weekly program meetings to ensure that plans are being completed according to regulations.
To prevent recurrence, the Director of Quality Management shall review client rehabilitation and treatment plans on a quarterly basis to ensure compliance with regulations.
The Quality Management Director will be responsible for ensuring implementation of the correction. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
Plans of correction for treatment and rehabilitation plans shall be re reviewed and updated at least every 60 days were submitted and approved by the Department for the January 28, 2021 and January 27, 2022 annual licensing inspections. Failing to ensure that treatment and rehabilitation plans were reviewed and updated at least every 60 days was again found to be a deficiency in the January 30, 2023 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program clinical staff shall update treatment and rehabilitation plans on a weekly basis.
The Program Director shall meet with staff during a weekly program meeting to ensure that all client treatment and rehabilitation plans are completed monthly.
The Quality Management Director will review each client on a quarterly basis to ensure that treatment plans are completed each month and report findings to Program Director.
To prevent recurrence The Chief Clinical Officer will facilitate a quarterly meeting with all Program Staff to review findings and develop plans for improvement when necessary.
The Chief Clinical Officer will ensure implementation of the correction.
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