INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 19, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, NorthEast Treatment Centers, 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of employee personnel records, the facility failed to document the required period of close supervision in one of one counselor assistant records reviewed.
The findings include:
Six personnel records were reviewed on November 18, 2014. One of the six personnel records reviewed was for the position of a counselor assistant. Employee #2 required 6 months close supervision based on her bachelor degree and not having at least one year of clinical experience. Employee #2 was hired on February 14, 2014 and their supervision started February 25, 2014 and was to end on August 14, 2014. There were several supervision notes missing from February 2014 through August. The last supervision note reviewed was August 4, 2014.
The following are the weeks where supervision notes were not documented for review during the licensing inspection:
The week of May 26, 2014
The week of June 2, 2014
The weeks of July 14, 2014 and July 28, 2014
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director met with the Clinical Supervisor on November 21, 2014 to review regulatory standards pertaining to supervision of Counselor Assistants. The Program Director and Clinical Supervisor reviewed the need to clearly document weekly supervision over all Counselor Assistants. The Clinical Supervisor will ensure provision of weekly supervision to all Counselor Assistants, which will be monitored on a monthly basis, through a review of personnel files conducted by the Program Director. Employee #2 will receive an additional three weeks of supervision in order to ensure compliance with the supervised supervision standard. These additional weeks of supervision will begin the week of December 8, 2014 and will be concluded the week of December 22, 2014. |
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, the facility failed to provide documentation of TB/STD training in two of six personnel records reviewed.
The findings include:
Six personnel records were reviewed on November 18, 2014 for documentation of HIV/AIDS and TB/STD training. The facility did not provide documentation of the required TB/STD training in personnel records # 3 and 6.
Employee # 3, a counselor, was hired May 18, 2012. TB/STD training was due to be completed no later than May 18, 2013. The facility failed to provide documentation of TB/STD training as of the date of this inspection.
Employee # 6, a counselor, was hired September 12, 2013. TB/STD training was due to be completed no later than September 12, 2014. The facility failed to provide documentation of TB/STD training as of the date of this inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will coordinate a scheduled TB/STD training to be conducted where Employees #3 and 6 will attend. The TB/STD training is schedule for January 22, 2015. The Program Director will review and monitor personnel files monthly to ensure all employees receive TB/STD training within one year or hire date to avoid future infractions regarding licensure standard 704.11. TB/STD trainings will be scheduled accordingly, by the Program Director to meet the training requirements for this standard. |
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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to document an informed and voluntary consent from the client for disclosure of information that indicated the specific information to be disclosed and the purpose of disclosure in five of eight client records reviewed.
The findings included:
Ten client records were reviewed on November 19, 2014. Eight client records were reviewed specifically for informed and voluntary consents from the clients. The facility failed to obtain an informed and voluntary consent from the client that included the specific information to be disclosed, who was receiving the information and the purpose of disclosure in client records # A, E, F, G and H.
This was discussed with the facility staff throughout the inspection.
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Plan of Correction
The Program Director met with Quality Assurance Team on November 20, 2014 to review and discuss the requirement pertaining to obtainment of informed and voluntary consent from each client as well as documentation of the date in which the staff signature was obtained. The Program Director educated the QA team regarding the need to ensure obtainment of specific information to be released on consent forms as well as the date in which the staff member signed as witness for all consent forms. The Quality Assurance Team will review every chart on a week to week basis in order to ensure the proper completion of all consents. The Program Director will select a sampling of charts each week as well to review consents as a means of ensuring continued compliance. On December 10, 2014, Clinical Supervisor removed all consents, which did not reflect informed and/or voluntary consent for client records #A, E, F, G and H. |