INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 9, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, RHD Lower Merion Counseling Services 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(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 and the Staffing Requirements Facility Summary Report, 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 within the regulatory timeframe in one of two applicable personnel records reviewed.
Employee #8 was hired as a counselor on October 22, 2022. The TB/STD training was due to be completed no later than October 22, 2023; however, the training was not completed at the time of inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All new LMCMS staff who will be working with D&A clients will be signed up for both HIV/AIDS and TB/STD trainings within their first 90 days. The LMCMS D&A Clinical Manager will ensure that these items are included in the training plan, which is completed within the first two weeks of hire. If the staff member does not sign up for an HIV/AIDS and TB/STD training by the end of their first 90 days, the staff member will not be permitted to work with D&A individuals in services until they are registered for their required trainings.
Every quarter, the LMCMS D&A Clinical Manager will report to the LMCMS Clinical Director the training registration statuses of all staff working with individuals in services. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on an administrative review of the facility's August 2023 through December 2023 fire drill logs, the facility failed to prepare alternate exit routes for each fire drill conducted.
Each fire drill log reviewed documented that the front door was used as the sole exit route.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The LMCMS Office Manager will update the fire drill schedule by 2/29/2024 to have all fire drills conducted within the first full week of each month. The updated fire drill schedule will stipulate which fire exit route is to be used in each fire drill to ensure that alternate exit routes are used. Completed fire drill logs will be submitted by the second full week of each month to the LMCMS Director of Operations for review. If the exit route scheduled to be used was not used in the drill, the Director of Operations will instruct the Office Manager to conduct a second drill for that month, to use the scheduled exit route, and to resubmit the corrected fire drill log. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review client records, the facility failed to document the specific information to be disclosed on a release of information form in one of five client records reviewed.
Client #2 was admitted on October 13, 2023 and was active at the time of inspection. The release of information form to a funding source was signed and dated by the client on September 15, 2023, but the release form did not include information that was specific and indicated "anything needed" to be disclosed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
LMCMS Clinician assigned to Client # 2 coordinated with client to complete new Releases of Information on 1/25/24. The new ROIs document specific information to be disclosed. This new ROI was uploaded into the client's chart on 1/25/24.
All LMCMS intake staff (Intake Specialist and Intake Therapist), D&A therapists, QA Team, and Resource Coordinators will be trained or retrained by the D&A Clinical Manager on the correct completion of a ROIs by 3/15/2024. This training will include specific information regarding confidentiality and how to identify which information needs to be disclosed. Attendance of this training will be mandatory and attendance will be tracked and stored in each employee's training file.
The D&A Clinical Manager will conduct monthly chart audits. These audits will include the review of submitted ROIs to ensure that releases properly document the specific information to be disclosed.
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709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review client records, the facility failed to document the purpose of the disclosure on a release of information form in one of five client records reviewed.
Client #2 was admitted on October 13, 2023 and was active at the time of inspection. The release of information form to a funding source was signed and dated by the client on September 15, 2023, but the release form documented that the purpose of the disclosure was "anything needed."
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
LMCMS Clinician assigned to Client # 2 coordinated with client to complete new Releases of Information on 1/25/24. The new ROIs document specific purposes for disclosure. These new ROIs were uploaded into the client's chart on 1/25/24.
All LMCMS intake staff (Intake Specialist and Intake Therapist), D&A therapists, QA Team, and Resource Coordinators will be trained or retrained by the D&A Clinical Manager on the correct completion of a ROIs by 3/15/2024. This training will include specific information regarding confidentiality and how to identify specific purposes for disclosure. Attendance of this training will be mandatory and attendance will be tracked and stored in each employee's training file.
The D&A Clinical Manager will conduct monthly chart audits. These audits will include the review of submitted ROIs to ensure that releases properly document the specific purposes for disclosure.
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