INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 26-27, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Impact Counseling Services LLC 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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709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
The facility failed to document the employee signed the annual performance evaluation in personnel records #3, 4, and 5 reviewed during the course of the inspection.
The findings were reviewed with the facility staff during the inspection.
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Plan of Correction
Facility Director with Impact Counseling Services, LLC will make necessary changes to all staff/personnel evaluation forms to include required space for employee signature and date of evaluation. This added changed has been made to our evaluations and will require staff/employee signature for completion of the form. The form will then be placed in the employee chart by the Program and Facility Directors.
The change to this form is effective immediately. No employee evaluation form will be placed into the designated employee chart without required signatures of directors and staff. |
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 a release of information form prior to disclosure in one of seven client records reviewed on September 27, 2019.
Client #5 did not have a documented release of information form for a family member prior to a family counseling session on September 4, 2019.
The findings were reviewed with the facility staff during the inspection.
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Plan of Correction
The Facility Director of Impact Counseling Services, LLC will review policy and procedures related to confidentiality and release of information forms with all staff on initial hire and during three clinicals throughout the year. This will ensure full understanding of requirements of release of information, family member involvement in sessions which require a signed release of information form by the patient prior to the session, and having the completed and signed release of information in the patients chart.
This policy will be reviewed with staff by the Facility Director of Impact Counseling, LLC on initial hire and during three clinical supervisions throughout the calendar year. This policy will be documented and signed by staff members. Documentation will be available for review in each staff members employee chart. This process will begin immediately on 10/18/19. |
715.28(a)(1-10) LICENSURE Unusual incidents
(a) A narcotic treatment program shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault by a patient.
(2) Inappropriate behavior by a patient causing disruption to the narcotic treatment program.
(3) Selling of drugs on the premises.
(4) Complaints of patient abuse (physical, verbal, sexual and emotional).
(5) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(6) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence.
(7) Incident with potential for negative community reaction or which the facility director believes may lead to community concern.
(8) Theft, burglary, break-in or similar incident at the facility.
(9) Drug related hospitalization of a patient.
(10) Other unusual incidents the narcotic treatment program believes should be documented.
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Observations
The facility failed to document a complete policy and procedure for unusual incidents. On September 27, 2019, the unusual incident policy and procedure was reviewed. It did not include #2, 7, 9 or 10.
The findings were reviewed with the facility staff during the inspection.
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Plan of Correction
The Facility Director of Impact Counseling, LLC has updated the policy and procedure manual for our Narcotic Treatment Program. This update includes the policy and procedure for unusual incidents at Impact Counseling Services, LLC. The Facility Director has included the following unusual incidents to the policy and procedure manual to include:
#2: Inappropriate behavior by a patient causing disruption to the narcotic treatment program.
#7: Incident with potential for negative community reaction or which the Facility Director believes may lead to a community concern.
#9: Drug related hospitalization of a patient
#10: Other unusual incidents the narcotic treatment program believes should be documented.
The Facility Director of Impact Counseling Services, LLC has added these incidents to the complete list of unusual incidents in our policy and procedure manual effective today 10/18/19. |