INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 30, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Trehab 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(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to ensure each employee had a written individual training plan, with input from both the employee and supervisor, in two of three personnel records reviewed.
Employee #1 was hired as the project/facility director on April 1, 1995. There was no individual training plan documented in the record at the time of the inspection.
Employee #2 was hired as the clinical supervisor on December 1, 2022. The individual training plan was signed by the employee on July 8, 2022; however, there was no documentation verifying it was completed with input from the supervisor.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In order to comply with regulation 704.11 (b) (1) Licensure: Individual training plan- (1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor, the following plan of correction will be implemented: Clinical Supervisor and QM Coordinator will inform Facility Director and D&A department staff that annual training plans are due by July 7, 2023. Clinical Supervisor will schedule half-hour appointments with each D&A department staff as well as the Facility Director to review each individual training plan for the fiscal year 2023-2024 prior to the July 7, 2023 deadline. Upon approval of the individual training plans, individual staff and Clinical Supervisor will sign the training plan, then Clinical Supervisor will immediately scan and email it to Fiscal Assistant to be filed in individual personnel files. Individual Staff will be provided the signed copy of the individual training plan to be included in their FY 23-24 training binder. |
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 personnel records, the facility failed to ensure that the project director and facility director completed at least 12 clock hours of annual training during the facility ' s July 1, 2021 through June 30, 2022 training year in one of one applicable personnel record reviewed.
Employee #1 was hired as the project/facility director on April 1, 1995, There was only 9.5 documented hours of training during the reviewed training year.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In order to comply with regulation 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, the following plan of correction will be implemented:
Clinical Supervisor and Quality Management Coordinator will review the status of Facility Director's training plan/training hours during scheduled monthly Quality Management meetings. Clinical Supervisor and Quality Management Coordinator will inform Facility Director of upcoming trainings during these meetings as well as provide him with email correspondence outside of meetings to facilitate completion of 12 hours of training annually. A section has been added to the QM Meeting Agenda titled: "Training Plan / Training Hours Review" with subtitles (categories) of, "Counseling Staff Training Status," "Support Staff Training Status," and "Facility Director Training Status." This consistent agenda item will prompt monthly review, allow for scheduling appropriate training and facilitate completion of hours.
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709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records, the facility failed to document an annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee, in two of two applicable personnel records reviewed.
Employee #1 was hired as the project/facility director on April 1, 1995. There was no annual written staff performance evaluation completed as of the date of inspection.
Employee #3 was hired as a counselor on January 31, 2022. There was no annual written staff performance evaluation completed as of the date of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In order to comply with regulation § 709.26. Personnel management. (b) The personnel records must include, but are not limited to: (3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee, the following plan of correction will be implemented:
Clinical Supervisor will submit a written request (email and/or memo) to Facility Director and Facility Director's administrative assistant within the first two (2) weeks of July for the completion of Facility Director's annual review by Trehab's Board of Directors during that month's scheduled board meeting (board meetings are conducted the third Wednesday of each month). This written request will prompt the review to become an official meeting agenda item. Clinical Supervisor will follow up with Facility Director and Facility Director's administrative assistant to obtain a copy of the completed annual review form completed and signed by Trehab's Board of Directors President.
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709.28 (c) (1) 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 must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom disclosure is made on consent to release information forms in seven of seven client records reviewed.
Each client record reviewed had a release of information form to a "certified recovery specialist " or "medical director"; however, each form in every record did not include the specific name of the person, agency, or organization to whom disclosure would be made.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
In order to comply with regulation 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 must be in writing and include, but not limited to: (1) Name of the person, agency, or organization to whom the disclosure is made, the following plan of correction will be made: During a clinical staff meeting scheduled for April 19, 2023, Clinical Supervisor will review this regulation and citation with all clinical staff. Clinical staff will be directed by Clinical Supervisor to specify who the disclosure is being made to, such as specific CRS names or agency, specific housing program, and specific medical director. QM coordinator will review all new charts to ensure these specifications are being addressed. If a disclosure is found to be non-specific in nature (ie, disclosure written out for CRS and not specifying what CRS), clinical staff will address this oversight with client and a new disclosure with specificity will be created and signed by client and clinical staff. |