INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 19, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Community Service Foundation, 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
Based on a review of personnel records, the facility failed to ensure that employee #6 received the minimum of 4 hours of TB/STD training within the regulatory timeframe. Employee #7 was hired as counselor on 10/3/16 and was due to have the TB/STD training no later than 10/3/17; however, the TB/STD training was not completed until 11/21/17.The findings were discussed with facility staff during the licensing process.
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Plan of Correction
As a result of the inspection, the project director and/or the facility director will ensure that employee trainings will be reviewed quarterly for compliance when the Quality Assurance Committee meets. This is changed to assure compliance with the regulation 704.11(c). This change will be effective February 1, 2018 |
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
Based on the review of 7 client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in 1 record reviewed. Client #7 was admitted on 4/27/17 and was discharged on 8/11/17. There was documentation that the facility had billed the funding source for services provided on 4/27/17; however, the consent to the funding source was not signed and dated until 5/1/17. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The project director and/or the facility director will ensure that all consent forms are signed prior to any service being provided. This is changed to assure compliance with regulation 709.28(c)Confidentiality. The clinical supervisors will supervise the counselors to implement this change starting February 1, 2108. |
709.34 (b) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(1) Documentation of the unusual incident.
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Observations
Based on the review of the facility's unusual incident policies and procedures on January 8, 2018, the procedures failed to include appropriate documentation on the implementation of the following items:(1) Implementation of a timely and appropriate corrective action plan, when indicated. (2) Ongoing monitoring of the corrective action plan.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The policy that specifically states the reporting of unusual incidents as outlined in 709.34 (a) is being revised by the Project Director and/or Facility Director with Quality Assurance Committee to be presented to the board of directors for approval at the next board meeting in Spring 2018. We will submit the board of directors approved POC by April 30, 2018 to DDAP. |