INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 30, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Lakeside NEPA, 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 the review of five personnel records, the project failed to ensure that one employee received at least four hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum.
Employee #5 was hired as a counselor assistant on October 30, 2023, and was to have the communicable disease training by October 30, 2024; however, there was no documentation in the personnel file of the completion of a Department approved TB/STD training as of the date of the inspection. Facility staff confirmed a training was not scheduled for the day of the inspection as well.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The facility failed to comply with 704.11(c)(1) Mandatory Communicable Disease Training. The facility failed to comply with having a staff member receive the minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis. The Executive Director will monitor all new employees to ensure all required training is completed within the first year of employment. The Executive Director implemented a tracking tool on 11/12/2024 with the list of required training and completion dates. All staff were informed on 11/12/2024 by the Executive Director of the importance of completing the required training during the first year on employment. The Executive Director reviewed the Training Management System site with the employees and assisted them with scheduling required training. Employee #5 will be in compliance on 12/13/2024. She is registered for the training at Marworth on 12/13/2024. |
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
Based on a review of administrative documents, the project director failed to prepare, annually update and sign a written manual delineating project policies and procedures.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
709.23 Project Director
The facility failed to comply with 709.23 Project Director. The facility failed to annually update project policies and procedures. The Projector Director was informed on 11/12/2024 and will review all policies and procedures annually. The Project Director will input the date the policy was reviewed and/or revised on the bottom of the header.
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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 the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one of seven records reviewed.
Client #7 was admitted on April 8, 2024, and was discharged on July 10, 2024. A release of information form for the funding source was not documented in the client record; however, the facility verified that billing had occurred.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
709.28(c) Confidentiality
The facility failed to comply with 709.28(c) Confidentiality. The facility failed to obtain informed and voluntary consent from a client for the disclosure of information. The Executive Director retrained the clinical staff members on 11/12/2024 on the importance of completing the informed and voluntary consents for all the clients funding sources. The Executive Director will review and monitor the informed and voluntary consents being completed and documented accurately during monthly supervision and random chart review audits.
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709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of outpatient client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in three of the seven records reviewed.
Client #1 was admitted on May 30, 2024, and was a current client at the time of the licensing inspection. The individual treatment and rehabilitation plan was completed on September 11, 2024; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
Client #4 was admitted on March 4, 2024, and was discharged on August 12, 2024. The individual treatment and rehabilitation plan was completed on March 25, 2024; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
Client #6 was admitted on July 3, 2024, and was discharged on September 25, 2024. The individual treatment and rehabilitation plan was completed on March 25, 2024; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
709.92(a)(2) Treatment and rehabilitation services
The facility failed to comply with 709.92(a)(2) Treatment and rehabilitation services. The facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan. Based on these findings the Executive Director discussed the expectations during the staff meeting on 11/12/2024. The Executive Director will review and monitor the individual treatment and rehabilitation plan document the type and frequency of treatment and rehabilitation services during monthly supervision and random chart review audits.
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