INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 1 through February 2, 2017 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, WES Corporation 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(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of the personnel records, the facility failed to document the completion of 12 clock hours of annual training required for the Project Director.
Employee #1 was hired as the project director on 5/1/2011 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from January 1, 2016 through December 31, 2016. The personnel record for employee #1 only included documentation of 10 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
WES training and development manager has been contacted and informed of Employee #1 insufficient training hours for the year 2016. The training and development manager was notified of the requirement for Employee #1 to have 12 training hours yearly. A new training needs assessment as well as an individual training plan has been developed for Employee #1. The training and development manager will insure the recommended trainings are scheduled and for Employee #1 and attendance is monitored.
To insure this does not happen again, the training and development manager has assumed responsibility to track and monitor full-time employees training hours. The training and development manager has been educated on required trainings for Substance Use program employees to complete. Training and development manager is required to locate and schedule full-time employees for all training needs. |
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 client records, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (c) the facility disclosed information prior to the patient signing an informed and voluntary consent to release form or beyond the limits of the signed consent form in client record #'s 1, 2, 3, 4, 5, 6, 8, 9, 10, 11, 12.
Client #1 was admitted on 2/18/16 and was an active client at the time of inspection. The record contained results from a urinalysis lab for a drug screen analysis which identified the client's presence in treatment; however, there was no documented consent to release information form or Qualified Service Organization Agreement in place for the lab prior to the disclosure.
Client # 2 was admitted on 5/23/16 and was an active client at the time of inspection. The record contained results from a urinalysis lab for a drug screen analysis which identified the client's presence in treatment; however, there was no documented consent to release information form or Qualified Service Organization Agreement in place for the lab prior to the disclosure.
Client # 3 was admitted on 10/18/16 and was an active client at the time of inspection. The record contained results from a urinalysis lab for a drug screen analysis which identified the client's presence in treatment; however, there was no documented consent to release information form or Qualified Service Organization Agreement in place for the lab prior to the disclosure.
Client # 4 was admitted on 9/7/16 and was an active client at the time of inspection. The record contained results from a urinalysis lab for a drug screen analysis which identified the client's presence in treatment; however, there was no documented consent to release information form or Qualified Service Organization Agreement in place for the lab prior to the disclosure.
Client # 5 was admitted on 3/31/16 and was an active client at the time of inspection. The record contained results from a urinalysis lab for a drug screen analysis which identified the client's presence in treatment; however, there was no documented consent to release information form or Qualified Service Organization Agreement in place for the lab prior to the disclosure.
Client #6 was admitted on 4/12/16 and was an active client at the time of inspection. The record contained results from a urinalysis lab for a drug screen analysis which identified the client's presence in treatment; however, there was no documented consent to release information form or Qualified Service Organization Agreement in place for the lab prior to the disclosure.
Client # 7 was admitted on 8/2/16 and was discharged from treatment on 10/28/16. The record contained results from a urinalysis lab for a drug screen analysis which identified the client's presence in treatment; however, there was no documented consent to release information form or Qualified Service Organization Agreement in place for the lab prior to the disclosure.
Client #8 was admitted on 1/18/16 and was discharged on 9/13/16. The record contained results from a urinalysis lab for a drug screen analysis which identified the client's presence in treatment; however, there was no documented consent to release information form or Qualified Service Organization Agreement in place for the lab prior to the disclosure.
Client #9 was admitted on 2/10/16 and was discharged on 7/20/16. The record contained results from a urinalysis lab for a drug screen analysis which identified the client's presence in treatment; however, there was no documented consent to release information form or Qualified Service Organization Agreement in place for the lab prior to the disclosure.
Client #10 was admitted on 12/5/15 and was discharged on 3/16/16. The record contained results from a urinalysis lab for a drug screen analysis which identified the client's presence in treatment; however, there was no documented consent to release information form or Qualified Service Organization Agreement in place for the lab prior to the disclosure.
Client #11 was admitted on 10/21/16 and was discharged on 5/18/16. The record contained results from a urinalysis lab for a drug screen analysis which identified the client's presence in treatment; however, there was no documented consent to release information form or Qualified Service Organization Agreement in place for the lab prior to the disclosure.
Client #12 was admitted on 11/6/15and was discharged on 5/18/16. The record contained results from a urinalysis lab for a drug screen analysis which identified the client's presence in treatment; however, there was no documented consent to release information form or Qualified Service Organization Agreement in place for the lab prior to the disclosure.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facility supervisor has met with the entire Substance Use program team to train them on the new procedure of obtaining release of information for each client seen in the program. The team has been instructed to obtain a release of information for the laboratory used for urinalysis for clients indicated during the site inspection, as well as for every existing active member in the program upon their return for services. Each active member will have a release of information for the laboratory used for urinalysis within 30 days.
To insure this does not happen again, a procedure has been included in the initial intake process in which each client will have a release of information for the laboratory upon entry into the program and will be updated yearly if the client is still an active member. |
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 client records, client #'s 1, 2, 3, 4, 5, 7, 8, 9, 11 had treatment plan updates completed after the regulatory timeframe or missing at the time of the inspection.
Client #1 was an active client at time of inspection. A comprehensive treatment plan was completed 2/29/16 and the next update was due no later than 4/29/16; however, the treatment plan update from 4/29/16 was not done at time of inspection.
Client #2 was an active client at time of inspection. A treatment plan update was completed 7/26/16 and the next update was due no later than 9/26/16; however, the treatment plan update from 9/26/16 was not done at time of inspection.
Client #3 was an active client at time of inspection. A treatment plan update was completed 11/10/16 and the next update was due no later than 1/10/17; however, the treatment plan update from 1/10/17 was not done at time of inspection.
Client #4 was an active client at time of inspection. A treatment plan update was completed 11/7/16 and the next update was due no later than 1/7/17; however, the next update due 1/7/17 was not completed at time of inspection.
Client #5 was an active client at time of inspection. A treatment plan was completed 4/20/16 and the next update was due no later than 6/20/16; however, the next update was not completed until 7/5/16. A treatment plan was completed 10/19/16 and the next update was due no later than 12/19/16; however, the next update was not completed until 1/3/17.
Client #7 was admitted on 8/2/16 and was discharged 10/28/16. A treatment plan update was completed 8/9/16 and the next update was due no later than 10/9/16; however, the next update was not completed at time of inspection.
Client #8 was admitted on 1/18/16 and was discharged 9/13/16. A treatment plan was completed 2/2/16 and the next update was due no later than 4/2/16; however, the next update not done at time of inspection.
Client #9 was admitted on 2/10/16 and was discharged 7/20/16. A treatment plan was completed 2/16/16 and the next update was due no later than 4/16/16; however, the next update not done at time of inspection.
Client #11 was admitted on 10/21/15 and was discharged 5/18/16. A treatment plan update was completed on 10/29/15 and the next update was due no later than 12/29/15; however, the next update was not completed until 1/7/16. A treatment plan update was completed on 3/1/16 and the next update was due no later than 5/1/16; however, the next update was not completed at time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff have been directed to document successful and non-successful attempts to update treatment plans within 60 days. The attempts to update treatments plans will be documented within a Progress note/Case management note/Collateral contact. Staff meeting has taken place to re-educate team on requirements and timelines of treatments plans. Staff has been instructed when individuals do not show for scheduled appointments where treatment plan updates was the intend focus of session to either; update treatment without the individual present along with a with note to inform why signature and participant involvement is not included or to do a progress not explaining specifically treatment plan is currently due for specified date any why it is not completed.
For those individuals who discontinue the program and are not quite eligible for discharge, the following will occur; update treatment without the individual present along with a with note to inform why signature and participant involvement is not included or to do a progress not explaining specifically treatment plan is currently due for specified date any why it is not completed.
To insure this does not happen again Program Director and Quality Assurance team will monitor weekly for this area of compliance. Staff meetings will also be a form of monitoring compliance and review of guidelines. |