INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 4, 2016 by staff from the Division of Drug and Alcohol Program Licensure. 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(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 a review of personnel records, the facility failed to document that staff persons and volunteers received a minimum of four hours of tuberculosis, sexually transmitted diseases and other health related topics using a Department approved curriculum in two of three personnel records.
The findings include:
Three personnel records requiring documentation of staff completion of four hours of tuberculosis, sexually transmitted diseases and other health related topics were reviewed on January 4, 2016. The facility failed to document the completion of the required TB/STD training in personnel records # 4 and #5.
Employee # 4 was hired on 7/16/01 and promoted to Project Director in May of 2011. TB/STD training was due to be completed no later than July of 2003. The facility failed to document the completion of the required four hours of TB/STD training.
Employee # 5 was hired as a Program Support Specialist on 11/4/99. TB/STD training was due to be completed no later than 11/4/01. The facility failed to document the completion of the required four hours of TB/STD training.
These findings were discussed with the facility staff during the licensing process.
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Plan of Correction
Employees #4 and #5 have been notified and identified to WES Training and Development Supervisor of non-compliance status for Basic HIV and TB/STD by Program Director. WES Training and Development Supervisor have been notified to research and inform Program Director of the upcoming training dates for both Basic HIV and TB/STD in order to register Employees #4 and #5.
Both Employee #4 and #5 will fulfill the respective trainings for which they are out of compliance, and an individualized training plan has been completed for both Employees #4 and #5 to reflect the training need and time frame to have the training completed.
To insure this does not recur for future employees, each employee's individualized training plan will include Basic HIV and TB/SDT training to be completed within their first 6 months of employment to insure employees meet the requirement within a year.
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709.28(c)(2) 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. The consent shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for disclosure of information contained in the client record which shall be in writing and include, but not be limited to specific information disclosed, in seven out of seven client records.
The findings included:
Seven client records requiring an informed and voluntary consent from the client were reviewed on January 4, 2016. The facility failed to obtain an informed and voluntary consent from the client, including the specific information to be disclosed, in client records # 1, 2, 3, 4, 5, 6, and 7.
Client #1 was admitted on 1/23/15 and discharged on 12/2/15. A Consent to Release form dated 1/23/15 had the option for "relevant records" checked off without indicating the specific information to be released to the insurance company.
Client #2 was admitted on 11/6/14 and discharged on 8/17/15. A Consent to Release form dated 11/5/14 had the option for "relevant records" checked off without indicating the specific information to be released to the insurance company.
Client #3 was admitted on 10/27/15 and still an active client at the time of the inspection. A Consent to Release form dated 6/08/15 had the option for "relevant records" checked off without indicating the specific information to be released to the insurance company.
Client #4 was admitted on 6/5/15 and still an active client at the time of the inspection. A Consent to Release form dated 6/05/15 had the option for "relevant records" checked off without indicating specific information to be released to the insurance company.
Client #5 was admitted on 6/18/15 and still an active client at the time of the inspection. A Consent to Release form dated 6/18/15 had the option for "relevant records" checked off without indicating specific information to be released to the insurance company.
Client #6 was admitted on 7/29/15 and still an active client at the time of the inspection. A Consent to Release form dated 7/29/15 had the option for "relevant records" checked off without indicating specific information to be released to the insurance company.
Client #7 was admitted on 6/18/15 and discharged on 11/30/15. A Consent to Release form dated 6/18/15 had the option for "relevant records" checked off without indicating specific information to be released to the insurance company.
These findings were discussed with the facility staff during the licensing process.
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Plan of Correction
After discussion with inspector on 1/4/16, WES Drug and Alcohol program is no longer using the broad statement "Relevant Records" to identify why records are needed or to describe the information to be released. Documentation was given to the program director by inspector on 1/4/16 to explain and describe the limitations and descriptions of what should be included in the release of information.
To insure this does not recur, an in-service training for all staff responsible for completing releases of information will be scheduled to occur by 2/29/2016. The training will focus on how to complete release of information and what should and should not be included. Release of information should be specific to the agency or entity for which information is being requested. We will reference and use the documentation given by the inspector on 1/4/16 as a guideline:
Code 255.5
(1) Whether the client is or is not in treatment
(2) Client's prognosis
(3) The nature of the project
(4) A brief description of the client's progress.
(5) A short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse.
Any new employees to the program will receive this training during their initial supervision period.
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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, the facility failed to document treatment and rehabilitation plan reviews and updates within sixty days, in five of five client records.
The findings include:
Five client records requiring treatment plan reviews and updates were reviewed on January 4, 2016. The facility failed to document treatment plan review and updates within sixty days, in client records # 1, 2, 4, 5, and 7.
Client #1 was admitted on 1/23/15 and discharged on 12/2/15. The comprehensive treatment plan was completed on 6/14/15. A treatment plan update was due by 8/14/2015. The facility failed to document the completion of a treatment plan update.
Client #2 was admitted on 11/6/14 and discharged on 8/17/15. The comprehensive treatment plan was completed on 2/23/15. A treatment plan update was due by 4/23/2015. The facility failed to document the completion of a treatment plan update.
Client #4 was admitted on 6/5/14 and was still an active client at the time of the inspection. The comprehensive treatment plan was completed on 2/23/15. A treatment plan update was due by 4/23/2015. The facility failed to document the completion of a treatment plan update.
Client #5 was admitted on 6/18/15 and was still an active client at the time of the inspection. The facility failed to document the completion of an initial treatment plan, a comprehensive treatment plan, and treatment plan update.
Client #7 was admitted on 6/18/15 and discharged on 11/30/15. The comprehensive treatment plan was completed on 6/25/15 and 8/26/15. A treatment plan update was due by 10/26/15. The facility failed to document the completion of a treatment plan update.
These findings were discussed with the facility staff during the licensing process.
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Plan of Correction
A formula based spread sheet has been developed to calculate when an individual is due for their treatment plan. The spread sheet will be reviewed weekly during staff team meetings by the supervisor to remind staff of the upcoming dates for completion. Treatment plans will be done every 60 days as per state guidelines.
To insure this does not recur, during staff meetings, the supervisor will go through the spread sheet to announce upcoming due dates, and will also update the spreadsheet with new dates given by staff. This will insure effectiveness and keep accuracy; and will occur weekly. The program director will also monitor and make sure this practice is consistent. |
709.93(a)(8) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on the review of client records, the facility failed to document a complete client record on an individual which includes information relative to the client's involvement with the project to include, but not limited to, case consultation notes in three of four client records.
The findings include:
Four client records requiring documentation of at least one quarterly case consultation were reviewed January 4, 2016. The facility failed to document the completion of a quarterly case consultation in client record #1, 2, and 7.
Client #1 was admitted 1/23/15 and discharged 12/2/15. There was no quarterly case consultation documented at the time of the inspection.
Client # 2 was admitted 11/6/14 and discharged 8/17/15. There was no quarterly case consultation documented at the time of the inspection.
Client # 7 was admitted 6/18/15 and discharged 11/30/15. There was no quarterly case consultation documented at the time of the inspection.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Case Consultations have immediately begun for program members starting 1/6/16. A case consultation note has been developed to document discussion and treatment. Case consultations will include; the client, program supervisor, clinician, family member/member support, external supports when applicable. Documented Case Consultations will occur every 90 days.
To insure this does not recur, program supervisor and director will monitor and review caseloads during staff supervision times to insure members are receiving 90 day consultations.
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