INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 13, 2019 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, Center For Families 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 employee #5, a counselor hired on March 15, 2018, received both of the required communicable disease trainings within the regulatory timeframe, based on a review of the facility's Staffing Requirement Facility Report and the employee's personnel file.The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Employee #5 will be receiving her HIV/AIDS training on 9/12/19 when she has returned from maternity leave
Employee #5 will be receiving her TB/STD training on 9/19/19 when she has returned from maternity leave.
Executive Director is responsible for implementing corrective actions.
To ensure continued compliance, a tracking checklist will be kept and monitored by Executive Director.
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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
The facility failed to ensure counseling areas could not be seen or heard from outside the counseling room. Based on a physical plant inspection, the large group counseling room on the first floor had windows facing the parking lot that were not covered. This allowed the sessions to be seen from outside of the facility.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Group room received a treatment on the glass on 6/17/19 to shield any person walking in the parking lot to visibly see into the group room.
Executive Director was responsible for ensuring the window met the requirements.
To ensure continued compliance, monthly and quarterly walk throughs will inspect the facility for confidentiality breaches. These will be documented. |
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 ensure that an informed and voluntary consent to release information form to the client's funding source was kept within the guidelines of 4 PA code 255.5 in twelve of twelve records reviewed. All the funders' consent to release information forms allowed for the release of progress and treatment reports, school transcripts and records, medical history and physical, discharge planning and summary, psychosocial history, psychiatric evaluation, substance abuse treatment records, and urine drug screen results. There was no documentation in the client records that any of the above information was released to the funders.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Releases of information will be updated by August 13 2019 to meet standards of 709.28 (c) and to include only information pertinent to 4 PA Code 255.5:
1) whether or not the client is in treatment, 2) client's prognosis, 3) nature of the project, 4) brief description of client's progress, and 5) a short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse, in accordance with 4 PA Code 255.5.
The Director of Compliance is responsible for making sure the correct form is distributed to the team and implemented.
This new form will be added to the quarterly audit checklist. |