INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 3, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, John F. Kennedy Behavioral Health 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of personnel records, the facility failed to ensure that clinical supervisors, who have not functioned for 2 years as supervisors in the provision of clinical services, completed a core curriculum in clinical supervision in one of one applicable personnel records reviewed.
Employee # 3 was hired as a clinical supervisor on October 12, 2020. There was no documentation of clinical supervision experience prior to being hired and no documentation that the clinical supervision core curriculum training was completed as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
704.6(c) Core Curriculum- Supervisor Training
The Clinical Supervisor of the Co-Occurring Outpatient Program has been registered for the approved DDAP Clinical Supervision core curriculum training through PESI Inc. To ensure that a Clinical Supervisor, who has not functioned for 2 years as a supervisor in the provision of clinical services, completes a core curriculum in clinical supervision, the agency will incorporate this requirement in the job description of the new hire. The Facility Director will monitor the status of training and if after 6 months the Clinical Supervisor is unable to attend the DDAP core curriculum training, the agency will utilize one of the external clinical supervision trainings that have already been approved by the DDAP training department. Completion date: 12/15/2021
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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 all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in one of four applicable personnel records reviewed.
Employee # 5 was hired as a counselor on March 9, 2020 and was due to have the HIV/AIDS training and the TB/STD training no later than March 9, 2021. The HIV/AIDS training was not completed until May 12, 2021 and the TB/STD training was not completed until May 25, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will ensure that all staff will receive a minimum 6 hours of HIV/AIDS and at least 4 hours of TB/STD trainings within the first year of employment. In situations where outside trainings are not offered or delayed, the Clinical Supervisor will develop a training curriculum based on the HIV/AIDS & TB/STD licensing alerts provided by DDAP. Employee #5 completed the required HIV/AIDS & TB/STD trainings in May 2021.
Completion Date: 01/01/2022
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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 ensure that all informed and voluntary consent to release information forms were signed and dated by the client in nine of twelve client records reviewed.
Client #3 was admitted on October 14, 2020 and was still active at the time of the inspection. Release of information forms to a funding source, a transportation agency, a primary care physician, and an emergency contact were present in the record; however, all the consent forms did not have the dated signatures of the client.
Client #4 was admitted on August 20, 2020 and was still active at the time of the inspection. Release of information forms to a funding source, a transportation agency, a primary care physician, and an emergency contact were present in the record; however, all the consent forms did not have the dated signatures of the client.
Client #5 was admitted on January 25, 2021 and was still active at the time of the inspection. Release of information forms to a funding source, a transportation agency, a primary care physician, and an emergency contact were present in the record; however, all the consent forms did not have the dated signatures of the client.
Client #6 was admitted on January 27, 2020 and was still active at the time of the inspection. Release of information forms to a funding source, a transportation agency, a primary care physician, and an emergency contact were present in the record; however, all the consent forms did not have the dated signatures of the client.
Client #7 was admitted on June 8, 2020 and was discharged November 4, 2020. Release of information forms to a funding source, a transportation agency, a primary care physician, and an emergency contact were present in the record; however, all the consent forms did not have the dated signatures of the client.
Client #8 was admitted on March 24, 2016 and was discharged September 17, 2021. Release of information forms to a funding source, a transportation agency, a primary care physician, and an emergency contact were present in the record; however, all the consent forms did not have the dated signatures of the client.
Client #9 was admitted on July 13, 2020 and was discharged June 1, 2021. Release of information forms to a funding source, a transportation agency, a primary care physician, and an emergency contact were present in the record; however, all the consent forms did not have the dated signatures of the client.
Client #10 was admitted on March 24, 2015 and was discharged October 26, 2021. Release of information forms to a funding source, a transportation agency, a primary care physician, and an emergency contact were present in the record; however, all the consent forms did not have the dated signatures of the client.
Client #12 was admitted on May 22, 2020 and was discharged September 14, 2021. Release of information forms to a funding source, a transportation agency, a primary care physician, and an emergency contact were present in the record; however, all the consent forms did not have the dated signatures of the client.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
709.28 (c) (4) Licensure Confidentially:
Every active client in treatment will meet in-person with their counselor to complete a new set of consent forms. Every consent form, including but not limited to: funding source; transportation agency; primary care physician, and emergency contact will contain a dated signature of the client. The Clinical Supervisor will review client records on a weekly basis to ensure that all informed and voluntary release of information forms are signed and dated by the client. The Clinical Supervisor is responsible for ensuring on going compliance with the regulatory requirement.
Completion Date: 12/30/21
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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 document that treatment plans were reviewed and updated at least every 60 days in six of twelve client records reviewed.
Client # 1 was admitted on April 8, 2021 and was still active at the time of the inspection. The comprehensive treatment plan was completed on April 8, 2021 and a treatment plan update was due no later than June 8, 2021. However, the update was not completed until July 28, 2021.
Client # 3 was admitted on October 14, 2020 and was still active at the time of the inspection. A treatment plan update was completed on May 20, 2021 and the next update was due no later than July 20, 2021. However, the update was not completed until August 30, 2021.
Client # 6 was admitted on January 27, 2020 and was still active at the time of the inspection. A treatment plan update was completed on May 27, 2021 and the next update was due no later than July 27, 2021. However, the update was not completed until August 17, 2021.
Client #8 was admitted on March 24, 2016 and was discharged September 17, 2021. A treatment plan update was completed on March 26, 2021 and the next update was due no later than May 26, 2021. However, the update was not completed until June 1, 2021. Additionally, a treatment plan update was completed June 1, 2021 and the next update was due no later than August 1, 2021. However, the update was not completed until September 10, 2021.
Client #9 was admitted on July 13, 2020 and was discharged June 1, 2021. A treatment plan update was completed on March 29, 2021 and the next update was due no later than May 29, 2021. However, the update was not completed at the time of inspection.
Client #12 was admitted on May 22, 2020 and was discharged September 14, 2021. A treatment plan update was completed on August 9, 2020 and the next update was due no later than October 9, 2020. However, the update was not completed until April 29, 2021.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
709.92(b) Treatment and Rehabilitation Services
The Clinical Supervisor will implement and provide staff training on a new caseload tracking protocol that staff will update weekly, to show the completion of treatment plan updates, at minimum every 60 days. The tracking form will be reviewed with each counselor during weekly clinical supervision and will be monitored by the Clinical Supervisor to ensure treatment plan updates are completed on a timely basis. Completion Date: 12/15/2021
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