INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 28, 2019 and March 1, 2019 of Berks Counseling Center 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, Berks Counseling 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
Based on review of personnel records, the facility failed to ensure each employee had an annual training plan.
Employee #1 was hired on February 1, 1988 and did not have a 2019 annual training plan.
Employee #3 was hired on August 20, 2018 and did not have a 2019 annual training plan.
Employee #7 was hired on August 21, 2018 and did not have a 2019 annual training plan.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
We have adjusted the orientation process to include writing the initial training plan to ensure completion for all new hires. The CEO was informed that her training plan was missing and that it needs to be completed on an annual basis. The CQI department is monitoring training to ensure compliance. |
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 files, the facility failed to ensure all employees have the required HIV/AIDS and TB/STD training within the required timeframe. Employee #20 was hired on July 10, 2017 as a counselor. HIV/AIDS and TB/STD training was due on July 10, 2018. As of the date of the inspection, these two trainings had not been completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
HIV/AIDS and TB/STD training will be offered internally a minimum of twice per year. It will be offered at a higher frequency as needed to accommodate increased hiring periods. Employee #20 is scheduled for both trainings 4/1719 and 4/18/19. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
A review of fire drill logs was conducted during the onsite inspection. The fire drill log, dated February 28, 2019 indicated a drill was conducted at 12:15pm. At that time, Department of Drug and Alcohol Programs staff was present and a drill was not performed at that time. Facility failed to provide a corrected fire drill log and documentation from the building manager as to when the fire drill was actually conducted that month. In addition, the February 28, 2019 fire drill log stated "about 85" people participated and alternate routes stated "N/A".
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The office manager has been instructed how to complete the fire drill log completely. BCC has contacted the fire company to request confirmation that they were at the site. Receipt of this documentation is pending. The clinical director is responsible for monitoring the fire drill logs to ensure compliance. |
709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
Based on a review of client records, the facility failed to store files on secure data bases. In client #4's record, the client requested that a staff member not have access to their file. After the security change was made, IT requested the staff person attempt to log in to the client's file. On the third attempt, the staff member was able to access the client's file. This is a breach of the facility's electronic system based on printouts in the client's file. There was no confirmation in the client's file that the grievance has been addressed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The client's file was blocked from staff per the staff member's request, not the client's. Client's file is currently closed. BCC's IT department has restricted the client from all staff members effective 4/22/19, unless specifically assigned permission in the system. The CQI Director is responsible for ensuring appropriate restrictions occur.
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709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on the review of client records, the facility failed to document an informed and voluntary consent to release information form with all required information prior to the disclosure of information in client records #3 and #5.
Client #3 was admitted on October 2, 2018 and was still an active client at the time of the inspection. The consent to release information form, signed and dated on October 2, 2018, did not have a person or organization listed for whom the client is granting authorization to release information to.
Client #5 was admitted on March 8, 2018 and discharged on October 1, 2018. The consent to release information form, signed and dated on March 8, 2018, did not include what information was permitted to be disclosed.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A review will be conducted with all staff about properly completing releases of information by 5/31/2019. In addition, these specific staff members will be addressed regarding the incomplete releases. The CQI Director and all supervisors are responsible for ongoing chart reviews to ensure errors do not continue to occur. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of client records, the facility failed to inform clients of all of their rights. The "Patient Rights Treatment Expectations and Guidelines", which is acknowledged by the client as having been received, did not list "marital status" and "ethnicity" as ways in which the client will not be discriminated against. Clients #1, #2, #3, #4, #5, #6 and #7 were not made aware of all of their rights.
These findings were reviwed with facility staff during the licensing process.
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Plan of Correction
Marital status and ethnicity will be added to the client rights by the office manager by 5/17/19. Clinical Director, Bonnie Triebig, will ensure and approve completion. |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on a review of client records, the facility failed to inform clients of all of their rights. The "Patient Rights Treatment Expectations and Guidelines", which is acknowledged by the client as having been received, states the client's "primary counselor may temporarily remove portions of the record prior to inspection if he/she feels that some information in the record may be detrimental to you at the time". Regulations state that the "project, facility or clinical director" may remove portions of the record. The regulation does not authorize the primary counselor to remove portions of the client record. Clients #1, #2, #3, #4, #5, #6 and #7 were provided with inaccurate information regarding this regulation.
These findings were reviwed with facility staff during the licensing process.
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Plan of Correction
The Patient Rights, Treatment Expectations, and Guidelines will be updated to include the correct language by the office manager by 5/17/19. |
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 seven client records, the facility failed to document treatment plan updates within the regulatory timeframe in three client records reviewed.
Client #2 was admitted on August 1, 2018 and was still active at the time of the inspection. A treatment plan was completed on August 17, 2018 and an update was due no later than October 16, 2018. The update was completed on November 6, 2018.
Client #5 was admitted on March 8, 2018 and discharged on October 1, 2018. A treatment plan was completed on March 15, 2018 and an update was due no later than May 14, 2018. The update was completed on June 30, 2018.
Client #7 was admitted on April 5, 2018 and discharged on December 10, 2018. A treatment plan was completed on April 5, 2018 and an update was due no later than June 3, 2018. The update was completed on June 29, 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinician will complete the update every 60 days with or without the client. At the time of the update, the clinician will sign it to indicate it was updated and re-sign it at the time it is reviewed with the client. The CQI Director will be responsible for monitoring treatment plans as part of the overall CQI plan. All staff will be educated regarding this change by 5/17/19. |