INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 10, 2007 to April 11, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on May 10, 2007.
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Plan of Correction
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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
The facility director fails to meet the qualifications as defined in 704.5 (c). The facility director is a diploma RN which is a credential that does not meet the degree requirements identified in the regulation.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
The facility failed to document feedback on all completed training.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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
The facility failed to document HIV/AIDS and TB/STD training for thirteen out of fourteen staff members. Although all staff has documented HIV/Aids and TB/STD training, the training received did not meet the the Department approved curriculum.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
157.23 (b) LICENSURE Patient records.
157.22 Patient records.
(b) Patient records shall be kept confidential in accordance with applicable Federal drug and alcohol regulations and the confidentiality requirements in 4 Pa. Code 255.4 and 255.5 (relating to UDCS: confidentiality and access to information and projects and coordinating bodies: disclosure of client-oriented information).
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Observations
The facility has failed to comply with state and federal confidentiality regulations. The "Consent Form", form 1110, includes a statement under the Release of Information paragraph that reads: " The hospital may disclose patient information it deems appropriate to any persons or corporation which is or may be liable under a contract to the hospital or to the patient or to a family member or employer of the patient for all or part of the hospital's charge.". This statement is a general consent to release information. General consents to release information are specifically prohibited at 42 CFR Part 2, Subpart C, Subsection 2.32 and are indirectly prohibited at 42 CFR Part 2, Subpart C, Subsection 2.31 and at 71 P.S. subsection 1690.108(b) and 28 Pa. Code Subsection 157.23(b) as it refers to 4 Pa. Code subsection 255.5. This form was found in all client records reviewed.
Three of three records reviewed included a consent to release information to insurance companies that exceeded 4 Pa. Code 255.5.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |