INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the April 26 - 28, 2010 licensure renewal inspection. The follow-up inspection was conducted on September 16, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Stairways Behavioral Health Outpatient Drug and Alcohol Program 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 and a plan of correction is due on October 11, 2010.
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Plan of Correction
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records and an interview with the project/facility director, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of three personnel records.
The findings include:
Five personnel records were reviewed on April 26, 2010. Four personnel records pertained to counselors. One personnel record required the completion of 25 clock hours of annual training. The facility failed to document 25 clock hours of annual training in personnel record # 4.
Employee # 4 was hired on July 11, 2007. The facility training year is from January through December. Employee # 4 had 4.5 hours of training documented for the 2009 training year.
An interview with the project/facility director on April 27, 2010, confirmed that employee # 4 completed only 4.5 clock hours of annual training from January to December 2009.
This is a repeat deficiency from the licensing inspection conducted on March 5, 2009.
** NOTE - The time period of observation is insufficient to determine compliance. The facility should re-submit the original plan of correction.
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Plan of Correction
Scheduled training hours for employee #4 for calendar year 2010 will exceed the requirement of twenty-five (25) hours of annual training. The Project Director will oversee employee #4's adherence to meeting her 2010 Training Plan.
The Facility Director revised the Annual Assessment of Individualized Training Needs on 5/18/2010 to include external trainings that will meet the regulation.
This will be completed by all employees in 12/2010 for the 2011 training year and annually thereafter. The Program Director will monitor the completion of the Annual Assessment of Individualized Training Needs.
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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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on the review of electronic client records, the facility failed to document that an informed and voluntary consent for the disclosure of information contained in the client record was obtained from the client.
The findings include:
Fifteen client records were reviewed on September 16, 2010. Consents to release information were reviewed in four client records. Fifteen records were reviewed, but only four records were reviewed to confirm that this issue is still in non-compliance. The Compliance Auditor/Safety Officer reported that because the client records are electronic, and the template for the release of information form had not been changed, it was non-compliant in all of the records. The client records reviewed are # 1, 2, 3, and 4.
The consent to release information forms documented in the client records and signed by the client, contained the statement that "the information released under this authorization is governed by Federal HIPAA guidelines. (the Health Insurance Portability and Accountability Act of 2001). Under certain circumstances, the information could potentially be re-disclosed by the person receiving the information and may no longer be subject to the privacy protection provided to me by law". This statement is in conflict with 42 CFR Part 2, Subpart C, subsection 2.32 which specifically prohibits the redisclosure of client identifying information..
An interview with the project/facility director and the Compliance Auditor/Safety Officer on September 16, 2010 confirmed the release of information forms used by the facility and documented in the client records contained the above statement.
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Plan of Correction
The electronic Release of Information for Drug and Alcohol Programs was edited. The statement "the information released under this authorization is governed by Federal HIPAA guidelines. (the Health Insurance Portability and Accountability Act of 2001). Under certain circumstances, the information could potentially be re-disclosed by the person receiving the information and may no longer be subject to the privacy protection provided to me by law" was removed and was replaced by:
"I understand that information released under this authorization is governed by Federal HIPAA guidelines (the Health Insurance Portability and Accountability Act of 2001) & 42 CFR Part 2."
The use of the corrected form is to be monitored by the Facility Director as well as the compliance office of Stairways Behavioral Health.
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709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on the review of client records and an interview with the project/facility director and compliance officer, the facility failed to document follow up information per policy, in four of eight client records.
The findings include:
Fifteen client records were reviewed on September 16, 2010. Eight client records reviewed were required to have follow up information. The policy states that for both referred and non referred clients, follow up is to occur within 7 days. The facility did not document follow up in client records # 10, 11, 13 and 15.
Client # 10 was admitted on July 22, 2010 and discharged on September 2, 2010. Follow up was due September 14, 2010. There was no documentation that follow up had been completed.
Client # 11 was admitted on June 30, 2010 and discharged on September 3, 2010. Follow up was due September 15, 2010. There was no documentation that follow up had been completed.
Client # 13 was admitted on June 4, 2010 and discharged on August 31, 2010. Follow up was due September 10, 2010. There was no documentation that follow up had been completed.
Client # 15 was admitted on July 26, 2010 and discharged on August 20, 2010. Follow up was due August 31, 2010. There was no documentation that follow up had been completed.
This was confirmed by the project/facility director and the compliance officer.
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Plan of Correction
At the Drug and Alcohol Outpatient Clinic General Staff meeting facilitated by the Facility Director and attended by all program staff, a notice will be given regarding the requirements of 709.93(a)(11). Program staff will be informed of their responsibility to make appropriate follow-up communication with discharged clients. Oversight of client follow-up will be the responsibility of the Facility Director. |