INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 7, 2018 through February 8, 2018 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 Northwestern Human Services of Delaware County, Inc. 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 a review of 9 personnel records, the facility failed to provide documentation of an individual training plan for 1 employee for the current training year, which was identified as 7/1/17 to 6/30/18.
Employee # 4 was hired as a counselor on 1/1/10 and was still in the position at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee # 4 currently has an individual training plan in place. The program has developed a schedule for individual training plans. Effective March 16th, 2018, all employees will have their individual training plans updated and/or reviewed for the current year. All training plans will be completed with the employee and their assigned supervisor. The program director will review and document the completion of each individual training plan no later than February 28 of the current year. The program director will be responsible for monitoring compliance with this process. |
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 9 personnel records, the facility failed to ensure that employee #7 received the minimum of 6 hours of HIV/AIDS training and 4 hours of TB/STD training within the regulatory timeframe. Employee #7 was hired as a counselor on 1/30/17 and was due to have HIV/AIDS training and TB/STD training no later than 1/30/18. As of the date of the inspection, there was no documentation of the completion of the HIV/AIDS and TB/STD trainings.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Employee #7 has been successfully registered for the HIV/AIDS training and will attend on March 27th, 2018. The program director has identified an TB/STD training and Employee # 7 is in the process of registering for this training on April 16th, 2018. Program director will continue ongoing monitoring of compliance with state mandated training through the NHS LMS (Learning Management System). The program director will submit all certificates of completion to the administrative assistant who will upload the completion of identified trainings to our internal tracking system. The program director will be responsible for checking the LMS system monthly to ensure that the information is accurate. |
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 9 personnel records, the facility failed to document the completion of 25 clock hours of annual training for the previous training year, 7/1/16 through 6/30/17, required for the position of counselor in 2 of 4 applicable personnel records.
Employee #5 was hired as a counselor on 10/01/05 and was still in that position at the time of inspection. The personnel record for employee #5 only included documentation of 21 hours of annual training for the training year reviewed.
Employee #8 was hired as a counselor on 9/24/12 and was still in that position at the time of inspection. The personnel record for employee #8 only included documentation of 4 hours of annual training for the training year reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The program director has developed a tracking/monitoring system to ensure compliance. All staff will be provided with a list of available state mandated trainings. During monthly supervisions, the direct supervisor will be responsible for reviewing what trainings have been successfully completed, and what trainings are outstanding. All staff will be required to follow the process which includes, attending the mandated training, obtaining the certificate of completion, and submitting the certificate of completion to the program director within 48 hours of receiving the certificate of completion. This certificate will serve as verification of attendance and will be submitted to the administrative assistant to be uploaded and recorded in LMS.
The program director will also be responsible for keeping a training binder which contains completion certificates that have been submitted and uploaded to LMS. This binder will serve as a backup record of trainings for staff.
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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
Based on the review of the fire drill logs for January 2017 to December 2017, the facility failed to document which exit route was used during each fire drill for the entire time period reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective March 16, 2018, all fire drill logs will be updated by the executive assistant to reflect what exits were used at the time of the fire drill. The Program Director will be responsible for maintaining copies of the fire drill logs in the office and will be responsible for filing the fire drill logs, and reviewing them after each drill. |
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
Based on the review of 7 client records, 4 client records had consent to release information forms that were missing required elements.
Client # 2 was admitted on 11/1/17 was an active client at the time of the inspection. There were two consent to release information forms both signed and dated on 11/1/2017; however, neither one contained a specific name, agency or organization for whom communication would be made with.
Client # 3 was admitted on 9/13/17 and was still an active client at the time of the inspection. There was a consent to release information form to a government agency signed and dated on 9/13/17; however, the consent form did not contain the purpose of the disclosure. Additionally, there was a consent to a primary care physician signed and dated on 9/13/17 by the witness; however, it did not specify the name, agency or organization for whom disclosure would be made to and the form did not include a dated client signature.
Client # 6 was admitted on 5/18/17 and was discharged on 1/29/18. There was a consent to release information form to a government agency signed and dated on 5/18/17; however, the consent form did not contain the purpose for the disclosure.
Client # 7 was admitted on 8/10/17 and was discharged on 11/18/17. There was a consent to release information form to a government agency signed and dated on 8/10/17; however, the consent form did not contain the purpose for the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #2 that was admitted on 11/1/17 will have his release of information updated by his FFS counselor to reflect the specific name, agency or organization that the information will be released to by March 16th, 2018.
Client #3 that was admitted on 9/13/17 will have her release of information updated by the FTE counselor to reflect the specific name, agency or organization that the information will be released to by March 16th, 2018.
Ongoing monitoring of compliance with be done by the program director and the clinical supervisor.
Effective March 16th, 2018, when charts are created and given to the clinical supervisor to review and sign assessments, the clinical supervisor will also review all ROIs before the chart is sent to medical records for permanent filing. On March 16th, all staff will receive an internal training facilitated by the program director that covers the following:
1) A review of PA Code 255.5.
2) Completing a Release of Information.
3) Client's rights and responsibilities.
All new clinical staff will attend the Confidentiality training offered by DDAP approved training sites within 6 months of employment.
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709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Based on the review of the facility's unusual incident reports, the facility failed to notify the Department within 3 business days following the unusual incidents below, which were discovered during the licensing process.
The incident dates and incident reasons are:
March 7, 2017 - Client death was reported to the agency on March 7, 2017; however, the death was not reported to the Department until May 8, 2017.
April 28, 2017 - Client death was reported to the agency on April 28, 2017; however, the death was not reported to the Department.
These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
Program director gathered information from DOH and reviewed licensing alert 5-97.
All clinical staff will be trained on the reporting requirements on March 16th, 2018 by the Clinical Supervisor. During the training, staff will review the documentation that is to be completed when there is an unusual incident. Staff will be given a post-test after the training. Program director will serve as the primary point of contact and staff have been made aware that the all incident reports should be submitted within 24 hrs of the incident.
The death of the Client will be sent to DOH / DDAP on DDAP's IR Form on or by March 16th, 2018.
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709.93(a) 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:
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Observations
Based on a review of 7 client records, the facility failed to provide a complete client record in 4 records.
Client #2 was admitted on 11/1/17 and was still an active client at the time of the inspection. The client record did not contain any records of service as of the date of the inspection.
Client #4 was admitted on 9/21/17 and was discharged on 12/14/17. The client record did not contain follow up information as of the date of the inspection.
Client #5 was admitted on 7/14/17 and was discharged on 11/28/17. The client record did not contain follow up information as of the date of the inspection.
Client #6 was admitted on 5/18/17 and was discharged on 1/19/18. The client record did not contain an aftercare plan, as wells as any follow up information as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #2's file will contain the completed record of services by March 16th, 2018. Follow-up will be completed by the counselors for Client #4, Client #5, Client #6 before March 16th, 2018. Client #6 will be contacted via telephone by the counselor to complete the full aftercare plan.
To ensure that the deficiency does not reoccur, the clinical supervisor will review all discharge charts and note any compliance issues before the chart is permanently closed out and archived in medical records. The review of discharge charts will be done within (5) days after the client's discharge and if a follow-up has not been completed, the clinical supervisor will notify the counselor and counselor will be responsible for updating the discharge follow-up form.
The discharge process has been updated and is effective March 16th, 2018.
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