INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 2, 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, Axiom Family Counseling Services 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(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
During a licensing inspection conducted on October 3, 2019, the facility failed to provide a mechanism to collect feedback on completed trainings in four of eight personnel records reviewed. Employee # 1 was hired for current position on August 20, 2011. Review of personnel records did not have a mechanism to collect feedback on completed trainings for the required 2018 training year.Employee # 2 was hired for current position on July 11, 2016. Review of personnel records did not have a mechanism to collect feedback on completed trainings for the required 2018 training year.Employee # 3 was hired for current position on March 12, 2015. Review of personnel records did not have a mechanism to collect feedback on completed trainings for the required 2018 training year.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The existing policy regarding completion of evaluation form upon completion of a training was amended to reflect Pennsylvania State regulations. In compliance with regulations, evaluations will be completed upon completion of in-house trainings only.
Compliance Officer will continue to provide evaluation forms to staff upon completing any trainings within the facility.
The evaluation form is required to be completed within 2 days of completing an in-house training and turned into the Compliance Officer.
Completion of evaluation forms will be monitored by Compliance Officer in audits of employee charts. |
709.28 (a) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(2) Identification of project staff having access to records, and the methods by which staff gain access.
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Observations
During a licensing inspection conducted on October 1-3, 2019, the project's policy and procedure manual failed to include a written procedure identifying project staff having access to records, and the methods by which staff gain access.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The existing policy regarding access to client medical records were clarified to specify which staff have access to client records and for what purposes staff have access to client records.
The existing procedures regarding methods of access to client records were clarified to specify how both paper chart and electronic records are accessed and who will have access to them |
709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
During a licensing inspection conducted on October 1-3, 2019, the project's policy and procedure manual failed to include a written procedure identifying that clients have the right to appeal a decision limiting access to their records to the director. These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The existing policy requiring all clients requesting an appeal to a decision limiting access to their records to follow appropriate procedure was clarified in the Policy and Procedure Manual to include specific process a client must complete to appeal said decision. The procedure previously outlined in Client Handbook is now outlined fully in the Policy and Procedure Manual.
The form utilized to complete an appeal to a decision limiting access to client records was incorporated into the EMR. That form will be provided to the client upon request by front office administration when the request is made.
The right to appeal a decision limiting access to client records remains within Client Handbook. The Client Handbook will continue to be reviewed in all intake/assessment sessions and provided to the client at time of intake/assessment. |
709.30 (5) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
During a licensing inspection conducted on October 1-3, 2019, the project's policy and procedure manual failed to include a written procedure identifying that the clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records. These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The existing policy requiring all clients requesting a correction of inaccurate, irrelevant, outdated, or incomplete information in their records to follow appropriate steps was clarified in the Policy and Procedure Manual to include specific process required to complete a correction of records. The procedure previously outlined in Client Handbook is now outlined in Policy and Procedure Manual.
The form utilized for all requested corrections of inaccurate, irrelevant, outdated, or incomplete information to a client's record was incorporated into the EMR. That form will be provided to the client upon request by front office administration when the request is made.
The right to request the correction of inaccurate, irrelevant, outdated, or incomplete information is identified within Client Handbook. The Client Handbook will continue to be reviewed in all intake/assessment sessions and provided to the client at time of intake/assessment |
709.30 (6) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
During a licensing inspection conducted on October 1-3, 2019, the project's policy and procedure manual failed to include a written procedure identifying that the clients have the right to submit rebuttal data or memoranda to their own records.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The existing policy requiring all clients requesting to submit rebuttal data to follow appropriate procedure was clarified in the Policy and Procedure Manual to include specific process a client must complete to submit rebuttal data or memoranda to their own records. The procedure previously outlined in Client Handbook is now outlined in Policy and Procedure Manual.
The form utilized in requesting to submit rebuttal data or memoranda to a client's own chart was incorporated into the EMR. That form will be provided to the client upon request by front office administration when the request is made.
The right to submit rebuttal data or memoranda to their own client record is identified within Client Handbook. The Client Handbook will continue to be reviewed in all intake/assessment sessions and provided to the client at time of intake/assessment |
709.32 (c) (2) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(2) Drug storage areas including, but not limited to, the secure storage of controlled substances and other abusable drugs in accordance with State and Federal regulations and program requirements.
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Observations
During a licensing inspection conducted on October 1-3, 2019, the project failed to follow their policy and procedure in the storage of medications. The policy states Vivitrol will be ordered daily per patient use and returned the same day if not used. The facility was observed storing Vivitrol onsite indefinitely.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The existing policy detailing the storage, ordering, and returning of Vivitrol medication was amended. Amendments were made regarding time of ordering, length of storage, and return of Vivitrol medication. Policy now allows for Vivitrol medication to be ordered upon need for the medication being determined by prescriber. The policy will be amended to not include time frame for removal of unused samples or prescriptions. |