INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 3, 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, Providence Living LLC d/b/a Providence Treatment 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
The facility failed to ensure that all staff completed the mandatory 4 hours of TB/STD training within regulatory time frame based on the review of the facility's Staffing Requirement Facility Summary Report.
Employee # 4 was hired as a counselor on October 18, 2017. The TB/STD training was due no later than October 18, 2018. However, the training was completed on April 2, 2019.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Effective 5/3/2019, during our weekly staff meeting, the Facility Director will present and discuss our new staff requirements check list, which includes a mandatory 4 hour TB/STD training within the first year of
employment (all clinical staff) and within 2 years after employment for non clinical staff.
Facility Director will revisit the checklist twice per year, or every six (6) months.
Facility Director will collect attestations regarding their attendance at the training scheduled on 5/3/2019. |
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
The facility failed to have the project director document that they had annually updated and signed the written policy and procedure manual.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Project Director, along with agency leadership, will meet quarterly to discuss and update sections of our policies and procedures. The Facility Director will be responsible to update policies, consistent with DDAP latest Standards, then the manual shall be signed by the Project Director annually with any updated standards.
This responsibility will be included in the annual training plan for the Facility Director. |
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 an informed and voluntary consent to release information form prior to the disclosure of information in 12 of 14 client records reviewed.
Client #1 was admitted into the partial program on February 12, 2019 and was active at the time of inspection. There was documentation that contact was made with the funding source; however, there was no consent to release information form to the funding source prior to the disclosures.
Client #2 was admitted into the partial program on February 18, 2019 and was active at the time of inspection. There was documentation that contact was made with the funding source; however, there was no consent to release information form to the funding source prior to the disclosures.
Client #3 was admitted into the partial program on March 6, 2019 and was active at the time of inspection. There was documentation that contact was made with the funding source; however, there was no consent to release information form to the funding source prior to the disclosures.
Client #4 was admitted into the partial program on August 20, 2018 and was discharged on October 1, 2018. There was documentation that contact was made with the funding source; however, there was no consent to release information form to the funding source prior to the disclosures.
Client #5 was admitted into the partial program on August 20, 2018 and was discharged on October 10, 2018. There was documentation that contact was made with the funding source; however, there was no consent to release information form to the funding source prior to the disclosures.
Client #6 was admitted into the partial program on November 30, 2018 and was discharged on January 24, 2019. There was documentation that contact was made with the funding source; however, there was no consent to release information form to the funding source prior to the disclosures.
Client #7 was admitted into the partial program on October 25, 2018 and was discharged on January 3, 2019. There was documentation that contact was made with the funding source; however, there was no consent to release information form to the funding source prior to the disclosures.
Client #8 was admitted into the outpatient level of care on October 1, 2018 and was active at the time of inspection. There was documentation that contact was made with the funding source; however, there was no consent to release information form to the funding source prior to the disclosures.
Client #9 was admitted into the outpatient level of care on January 24, 2019 and was active at the time of inspection. There was documentation that contact was made with the funding source; however, there was no consent to release information form to the funding source prior to the disclosures.
Client #10 was admitted into the outpatient level of care on January 3, 2019 and was active at the time of inspection. There was documentation that contact was made with the funding source; however, there was no consent to release information form to the funding source prior to the disclosures.
Client #13 was admitted into the outpatient level of care on May 8, 2018 and was discharged on August 27, 2018. There was documentation that contact was made with the funding source; however, there was no consent to release information form to the funding source prior to the disclosures.
Client #14 was admitted into the outpatient level of care on October 19, 2018 and was discharged on January 9, 2019. There was documentation that contact was made with the funding source; however, there was no consent to release information form to the funding source prior to the disclosures.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Effective 4/30/2019, all clients will sign a consent to release information to their respective insurers.
The Facility Director will conduct a chart review/audit quarterly to ensure compliance. |