INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 27, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Brookdale 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 Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to document the completion of 12 clock hours of annual training required for directors in employee #1's employee record.Employee #1 was hired as the project director on January 4, 2021 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 2023 through December 31, 2023. Employee #1's employee record documented 0 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
Specific Course of Action:
Means: The Project Director will receive reminders by the Compliance and Human Resources teams regarding Training hours Reminders will be sent to the Project Director quarterly.
Responsible Parties: The Project Director will be responsibile for obtaining the required training hours (12 hrs.) during the training year January through December.
The Project Director submitted 17 training hours on January 29, 2024 for the training period January 2024 thru December 2024.
Facility is in compliance as of 3/27/2024 |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of the client records, the facility failed to document that a copy of a client consent shall be offered to the client and a copy maintained in the client record in all fourteen client records reviewed.This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Specific Course of Action:
During the licensing process it was brought to the attention of the facility that we did not document that a copy of the patient consent was offered to the patient. The DBH Corporate office was contacted on 3/27/2024 and they inserted the following statement on 3/27/2024, "I understand I am entitled to a copy of this document in its completed form."
Means:
Responsible Parties: The Chief Compliance Officer will conduct a thorough review of all consents to identify any discrepancies or oversights on a yearly basis.
Facility is in Compliance as of 3/27/2024. |