INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 22, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Another Way, 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
The facility failed to ensure that staff received 6 hours of HIV/AIDS and at least 4 hours of STD/TB training within the required timeframes, in four of four records.
Employee # 4 was hired as a counselor on March 13, 2019. The STD/TB training was to be completed by March 13, 2020. There was no documentation that the training had been completed.
Employee # 5 was hired as a tech on July 28, 2017. The HIV/AIDS and the STD/TB training was to be completed by July 28, 2019. There was no documentation that the training had been completed.
Employee # 6 was hired as a tech on January 3, 2018. The HIV/AIDS and the STD/TB training was to be completed by January 3, 2020. There was no documentation that the training had been completed.
Employee # 7 was hired as a tech on August 18, 2018. The STD/TB training was to be completed by August 18, 2020. There was no documentation that the training had been completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
We had difficulty finding HIV STD/TB trainings being offered in the area. We had contacted a local health clinic that was willing to provide the DDAP approved Curriculum in February 2020. We currently have an agreement with this health agency to provide the required DDAP training. Due to COVID 19 we continued to be rescheduled. The Director spoke with this health agency and they are willing to offer it Virtually or in person in the future. This will resolve in the future employees not having HIV STD/TB.
Staff is required to have 6 hours AIDS/HIV training and at least four hours of TB/STD training which at the time of the survey 4 employees did not meet criteria.
The fiscal officer will be responsible for coordinating the training for staff members that do not have the trainings that are required.
The Fiscal Officer will maintain a spreadsheet with the trainings required to ensure the staff members have had the trainings.
We will be in full compliance after Oct 23rd. |
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
The facility failed to obtain an informed and voluntary consent from the client in four of seven records.
In client records # 2, 3, 4 and 5, information was released to the third-party payor. There was no consent to release information to the payors documented in the client records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
When Quality Assurance was done the release for County Funding was put in place of the third party funders release. The staff were retrained on the mandatory releases by the Facility Director. The Senior Behavioral Tech along with the Facility Director will continue Quality Assurance. In client records the senior behavioral tech when he assembles the chart will complete a orange colored release checklist to ensure we will remain in compliance with releases. We were in full compliance as of 9/19/20 |