INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 3, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Creative Health Services 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(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 eight personnel records, the facility failed to ensure that staff received at least four hours of TB/STD training and six hours of HIV/AIDS training in one record reviewed.Employee # 8 was hired as administrative support staff on November 25, 2019 and was due to have the TB/STD and HIV/AIDS trainings no later than November 25, 2021. There was no documentation in the personnel file of the completion of the TB/STD or HIV/AIDS trainings as of the date of the inspection.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Creative Health Services will ensure that the DDAP training requirements are met for each employee within the timeframe specified in 704.11
The Program Director will provide oversight to ensure this is completed. This will be implemented immediately and addressed by providing a list of required trainings to all staff to include expected timeframe. Employee #8 has been scheduled to complete the required trainings: TB/STD on April 21, 2022, and HIV/AIDS on May 26-May 27, 2022. |
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 a review of seven client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in one record reviewed. Client #1 was admitted on June 23, 2021 and remained active at the time of the inspection. The record contained documentation of communication with a probation officer, to whom the client signed informed and voluntary consent to release information form expired on August 4, 2020. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Creative Health Services will ensure that DDAP regulations stated under 709.28 confidentiality are met within the program. further training will be provided to those who require it.
This will be overseen by the Project Director and will occur immediately.
All files will be reviewed regularly to ensure releases are completed, signed and up to date. Ongoing supervision will be provided to support continued understanding of confidentiality. Client #1 was updated to reflect they are no longer on probation. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of seven client records, the facility failed to ensure that treatment and rehabilitation plans were reviewed and updated at least every 60 days in two of six applicable records reviewed.Client #4 was admitted on February 25, 2021 and discharged on January 26, 2022. A treatment plan update was completed on August 4, 2021, and the next one was due by October 4, 2021; however, no additional treatment plan updates were completed prior to the client ' s discharge. Client #5 was admitted on July 15, 2021 and discharged on February 14, 2022. The comprehensive treatment plan was completed on July 15, 2021, and a treatment plan update was due to be completed by September 15, 2021; however, the next treatment plan update was not completed until October 4, 2021. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As stated in 709.92 treatment and rehabilitation services Creative Health Services will complete treatment plan at least every 60 days.
This will be reviewed and monitored by clinical supervisors in individual and group supervision, on an ongoing basis. This will be overseen by the Project Director. This will occur immediately. |