INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 6, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, White Deer Run of York 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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704.6(b) LICENSURE Qualification Groups
704.6. Qualifications for the position of clinical supervisor.
(b) A clinical supervisor shall meet at least one of the following groups of qualifications:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 2 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 3 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 4 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person.
(4) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board and 3 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person. The individual shall also complete a Department approved core curriculum training which includes a component on clinical supervision skills.
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Observations
Based on a review of four personnel records, the facility failed to document that the one clinical supervisor met both the education and experiential qualifications for the position.Employee #3, who was hired as a clinical supervisor on December 14, 2023 and was still employed in that position at the time of the inspection, did not meet the experience requirements to be a clinical supervisor. At the time of the hire, the employee did not have 3 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person required to be a clinical supervisor with a bachelor's degree. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will follow counselor requirements from DDAP for hiring and supervision.
The facility will be sending a letter to request Act 66 flexibility in the hiring requirement.
The Program Director will review employee resumes prior to hiring to determine if they meet the requirements for a Counselor and proceed with the correct form of supervision.
Ongoing: Human Resources and the Campus
Director will determine if a candidate is to be hired and the requirements they will need. |
704.6(d) LICENSURE Addiction training
704.6. Qualifications for the position of clinical supervisor.
(d) If a clinical supervisor or lead counselor has less than 2 years of clinical experience working directly with the chemically dependent person, 6 of the training hours required in 704.11 (e)(2) and (f)(2) (relating to staff development program) during the first year of employment shall be in diseases of addiction.
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Observations
Based on a review of four personnel records, the facility failed to document that one clinical supervisor with less than two years of clinical experience working directly with the chemically dependent person completed 6 of the training hours during the first year of employment in diseases of addiction. Employee #3, who was hired as a clinical supervisor on December 14, 2023 and was still employed in that position at the time of the inspection did not have two years of clinical experience working directly with the chemically dependent person. Employee #3 did not have documentation of completing training in the diseases of addiction during the first year of employment. This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The facility will follow clinical supervisor requirements from DDAP for hiring and supervision.
The facility will be sending a letter to request Act 66 flexibility in the hiring requirement.
The Program Director will review employee resumes prior to hiring to determine if they meet the requirements for a clinical supervisor. Human Resources, Campus
Director and Facility Director will determine if a candidate is to be hired and the requirements they will need. |
704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of one applicable personnel record, the facility failed to document monthly meetings with the clinical supervisor and supervisor to discuss their duties and performances for the first 6 months of employment in that position.Employee #3, who was hired as a clinical supervisor on December 14, 2023 and was still employed in that position at the time of the inspection did not have documentation of supervision occurring monthly. This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Program Director will document monthly supervision meetings. Supervisions will be documented and kept in a binder for Quality Risk Manager to review monthly.
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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report and four personnel records, the facility failed to provide a sufficient number of staff persons with CPR certification and first aid training onsite during project ' s hours of operation. The Staffing Requirements Facility Summary Report documents that two staff members who are employed onsite have first aid training and there are no staff trained in CPR. This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Quality Risk Manager will explore which staff does not have part one of CPR training in Acadia/White Deer Run HealthStream, which will be completed in 30 days of this POC (4/12) and follow up with a RED Cross facilitator who has the mannequins to complete Part Two, which will be scheduled by Risk Manager and Nurse manager within 30 days of the HealthStream training. All CPR trainings will be completed by June 1, 2024. CPR Training cards will be submitted to Human Resources so Quality Risk Manager can monitor compliance. Quality Risk Manager will monitor monthly by confirming expiration dates. After NEO, those who need to be CPR certified will complete steps one and two will follow instructions identified above. |
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 four personnel records, the facility failed to document the completion of 12 clock hours of annual training required for the facility director.Employee #2 was hired as a facility director on September 5, 2022 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from January 1, 2023 through December 31, 2023. The facility failed to submit documentation of Employee #2 ' s training hours. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
This facility will ensure that the Clinical supervisor and Facility Director will complete a minimum of 12 hours of annual training in the designated areas. The Campus Director will meet the Facility Director on a monthly basis to ensure that they are progressing towards their annual training requirements of 12 hours. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report and personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors.Employee #4 was hired as a counselor on February 28, 2022 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from January 1, 2023 through December 31, 2023. The facility failed to submit documentation of Employee #4 ' s training hours. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will ensure that all counselors will complete at least 25 hours of training annually in the designated areas.
Over the next 90 days, the Program Director will meet with all counselors to ensure that they are completing training hours towards their required annual 25 hours minimum.
Ongoing: The Program Director will meet with each counselor on a quarterly basis to ensure that they are progressing towards their annual 25 hours of training requirements. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on the review of the facility ' s fire drill logs from April 2023 through December 2023, the facility failed to document whether a fire alarm or smoke detector was set off during the time of the drill for the months of April to December 2023 This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Due to this building being historic property. The Facility Director will be the designated person to set off the smoke detectors. In addition, the Facility Director will contact the landlord of this building to contact the City of York on how to seek a fire drill exception. In the meantime, fire drills will be conducted monthly during all shifts and documented in the fire drill manual. |
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 personal records, the facility failed to ensure that all employees have an annual written individual staff performance evaluation, copies which shall be reviewed and signed by the employee in one out of four personal records reviewed. Employee #2 was a hired as a facility director on September 5, 2022 and was still employed at the time of the inspection. The facility failed to submit documentation that Employee #2 had an annual staff performance evaluation. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The facility will ensure that all employees have their annual performance review. HR will have a copy of all performance reviews and a copy will be keep in the employee supervision binder. The Program Director will meet with each staff to compete their annual performance review. |
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 must 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 release of information to include specific information to be disclosed in two out of eleven records reviewed.Client #4 was admitted the partial hospitalization program level of care on December 7, 2023 and discharged on January 31, 2024. The record contained one informed and voluntary consent to release information to a legal entity signed by the client on December 13, 2023, the consent did not list the specific information to be disclosed. Client #8 was admitted to the outpatient level of care on October 23, 2023 and still active at the time of the inspection. The record contained one informed and voluntary consent to release information to a legal entity signed by the client on October 23, 2023, the consent did not list the specific information to be disclosed. This is a repeat citation from the March 25, 2022 and March 15, 2023 licensing inspections.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Quality Risk Manager will conduct a training on the consents at the facility by March 29, 2024, where employees will be trained on the correct procedures for obtaining consent. Program Director and Quality Risk Manager will pull four random charts weekly over the next eight weeks to review and document consents are being completed correctly. Ongoing, consents will be reviewed on monthly chart reviews and supervisions. |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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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 the disclosure of information contained in the client record that included the purpose of disclosure in one out of eleven records reviewed. Client #8 was admitted to the outpatient level of care on October 23, 2023 and was still active at the time of the inspection. The record contained one informed and voluntary consent to release information to a legal entity signed by the client on October 23, 2023, that had identified the purpose for disclosure as other, however no information was listed for what the other purpose was. This is a repeat citation from the March 15, 2023 licensing inspection.This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Quality Risk Manager will conduct a training on the consents at the facility by March 29, 2024, where employees will be trained on the correct procedures for obtaining consent. Program Director and Quality Risk Manager will pull four random charts weekly over the next eight weeks to review and document consents are being completed correctly. Ongoing, consents will be reviewed on monthly chart reviews and supervisions. The clients that are no longer in treatment will not receive a corrected consent, if the client is still active the client will be offered to sign a corrected release.
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709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
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Observations
Based on a review of administrative information, client records, personnel records, and the facility policy manual, the facility failed to develop a data collection and recordkeeping system that allows for the efficient retrieval of data needed to measure the project's performance in relationship to its stated goals and objectives.The following materials were requested however the facility was unable to provide them during the licensing process:The Staffing Requirement Facility Summary Report (SRFSR), qualifications for clinical staff, clinical staff supervision documents, training documentation, and CPR cards.This finding was reviewed with the facility during the licensing process.
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Plan of Correction
The facility will complete presubmission documentation including staffing summary report, training plans, work performances, and data collection form prior to the inspection. Facility is receiving technical support training on the presubmission process. Human Resources and leadership will review submissions.
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709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe of every fourteen days per the facility ' s policy and procedure manual in five out of six records reviewed.Client #1 was admitted on December 20, 2023 and was still active at the time of the inspection. A treatment plan was completed on January 3, 2024 and the next update was due no later than January 17, 2024; however, the next update was not completed until February 2, 2024. Client #2 was admitted on January 5, 2024 and was still active at the time of the inspection. A treatment plan was completed on January 14, 2024 and the next update was due no later than January 28, 2024; however, there was no documentation that one was completed. Client #3 was admitted on November 28, 2023 and was still active at the time of the inspection. A treatment plan was completed on December 8, 2023 and the next update was due no later than December 22, 2023; however, it was not completed until January 3, 2024. The next update was due no later than January 17, 2023; however, it was not completed until February 2, 2024. Client #4 was admitted on December 7, 2023 and discharged on January 31, 2024. A treatment plan was completed on December 21, 2023 and the next update was due no later than January 4, 2024; however, it was not completed until January 18, 2024.Client #6 was admitted on October 11, 2023 and discharged on December 7, 2023. A treatment plan was completed on October 13, 2023 and the next update was due not later than October 27, 2023; however, there is no documentation that one was completed. Client #9 was admitted on August 16, 2023 and discharged on October 15, 2023. A treatment plan was completed on August 19, 2023 and the next update was due no later than September 2, 2023; however, there was no documentation that one was completed.This is a repeat citation from the March 15, 2023 licensing inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility will ensure master treatment plan is completed every 14 days after the preliminary treatment plan. Program Director will provide a training to the counselors by March 29, 2024, by reviewing the policy on treatment plans. For the next 60 days Program Director will pull four random charts and review for master treatment plans. Program Director will review master treatment plans during supervision and monthly chart audits. |
709.83(a)(4) LICENSURE Client records
709.83. 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:
(4) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include case consultation in four out of four applicable records reviewed. Per the facility ' s policy and procedure manual, case consultation is completed every ninety days or at least once per level of care. Client #4 was admitted on December 7, 2023 and discharged on January 31, 2024. There was no documentation that a case consultation occurred. Client #5 was admitted on March 31, 2023 and discharged on May 5, 2023. The was no documentation that a case consultation occurred. Client #6 was admitted to the partial hospitalization program on October 11, 2023 and discharged on December 7, 2023 and was stepped down to the outpatient program on December 8, 2023. There was no documentation that a case consultation occurred. Client #9 was admitted to the partial hospitalization program on August 16, 2023 and discharged on October 15, 2023 and was stepped down to the outpatient program on October 18, 2023. There was no documentation that a case consultation occurred. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility will ensure case consults are completed every 90 days or in level of care changes. Clinical Director will provide a training to the counselors by March 22,2024, reviewing the policy on case consults. For the next 60 days Clinical Director will pull five random charts and review for case consults. Clinical Director will review case consults during supervision and monthly chart audits. |
709.83(a)(6) LICENSURE Client records
709.83. 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:
(6) Aftercare plans, if applicable.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include an aftercare plan in two out of four applicable records reviewed. Per the facility ' s policy and procedure manual, the aftercare plan is developed with the client prior to discharged and signed by the client. Client #4 was admitted on December 7, 2023 and discharged on January 31, 2024. There was no documentation that an aftercare plan was developed with the client. Client #5 was admitted on March 31, 2023 and discharged on May 5, 2023. The was no documentation that an aftercare plan was developed with the client. This is a repeat citation from the March 15, 2023 licensing inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility shall maintain a complete client record for each client which shall include aftercare plans and will be developed with the client prior to discharge and signed by the client. For the next 60 days, the Program Director will audit five charts per week to confirm that they contain aftercare plans which were developed prior to discharge and signed by the client.
The Program Director will conduct
quarterly audits to ensure that aftercare plans were developed prior to discharge and were signed by the client. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to document a complete psychosocial evaluation in three out of four applicable records. Client #7 was admitted on May 25, 2023 and discharged on July 21, 2023. There is no documentation a psychosocial evaluation was developed during the intake procedures. Client #10 was admitted on June 6, 2023 and discharged on August 8, 2023. There is no documentation a psychosocial evaluation was developed during the intake procedures. Client #11 was admitted on April 28, 2023 and discharged on September 27, 2023. There is no documentation a psychosocial evaluation was developed during the intake procedures. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility will ensure a complete psychosocial evaluation is completed during the drug and alcohol assessment. The Program Director will provide a training to the counselors by March 29, 2024. For the next 60 days Program Director will pull four random charts and review for a complete psychosocial evaluation. Program Director will review complete psychosocial evaluation during supervision and monthly chart audits. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to document a comprehensive treatment plan within guidelines established by the facility's policy and procedures manual in two out of five applicable client records reviewed. The facility ' s policy and procedures manual states the comprehensive treatment plan must be completed within fourteen days if they are in the Intensive Outpatient Program or twenty-one days if they are in outpatient program. Client #8 was admitted to the intensive outpatient program on October 23, 2023 and discharged on December 15, 2023 and was stepped down to the outpatient program on December 15, 2023 and is still active at the time of the inspection. A comprehensive treatment plan was completed on October 23, 2024; however, there is no documentation that it was developed with the client. Client #11 was admitted to the outpatient program on April 28, 2023 and discharged on September 27, 2023. A comprehensive treatment plan was due no later than May 19, 2023; however, it was not completed until July 5, 2023. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility will ensure master treatment plan is completed every 14 days after the preliminary treatment plan. Program Director will provide a training to the counselors by March 29, 2024, by reviewing the policy on treatment plans. For the next 60 days Program Director will pull four random charts and review for master treatment plans. Program Director will review master treatment plans during supervision and monthly chart audits. |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document proposed type of support service on individual treatment plans in three out of five applicable records reviewed.Client #7 was admitted on May 25, 2023 and discharged on July 21, 2023. The treatment plan dated June 7, 2023 did not include the proposed type of support service.Client #10 was admitted on June 6, 2023 and was discharged on August 8, 2023. The treatment plan dated June 29, 2023 did not include the proposed type of support service.Client #11 was admitted on April 28, 2023 and discharged on September 27, 2023. The treatment plan dated July 5, 2023 did not include the proposed type of support service.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility will ensure all treatment plans identify type of supportive service on individual treatment plans. Program Director will provide a training to the counselors by March 29, 2024, by providing a training on how to write treatment plans. For the next 60 days Program Director will pull four random charts and review treatment plans. Program Director will review treatment plans during supervision and monthly chart audits. |
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 plan updates within the regulatory timeframe of every sixty days per the facility ' s policy and procedure manual in one out of one applicable record reviewed.Client #11 was admitted on April 28, 2023 and discharged on September 27, 2023. A treatment plan was completed on July 5, 2023 and the next update was due no later than September 5, 2023; however, there was no documentation that one was completed. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Facility will ensure master treatment plan updates are completed every 60 days or in change of level of care. Program Director will provide a training to the counselors by March 29, 2024, by reviewing the policy on treatment plans. For the next 60 days Program Director will pull four random charts and review treatment plan/treatment plan updates. Program Director will review treatment plans/treatment plan updates during supervision and monthly chart audits. |
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 a review of client records, the facility failed to provide a complete client record, which is to include case consultation in two out of six applicable records reviewed. Per the facility ' s policy and procedure manual, case consultation is completed every ninety days or at least once per level of care. Client #7 was admitted on May 25, 2023 and discharged on July 21, 2023. There was no documentation that a case consultation occurred. Client #11 was admitted on April 28, 2023 and discharged on September 27, 2023. The was no documentation that a case consultation occurred. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility will ensure case consults are completed every 90 days or in level of care changes. Program Director will provide a training to the counselors by March 22,2024, reviewing the policy on case consults. For the next 60 days Program Director will pull five random charts and review for case consults. Program Director will review case consults during supervision and monthly chart audits.
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709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include an aftercare plan in two out of four applicable records reviewed. Per the facility ' s policy and procedure manual, the aftercare plan is developed with the client prior to discharged and signed by the client. Client #10 was admitted on June 6, 2023 and discharged on August 8, 2023. There was no documentation that an aftercare plan was developed with the client. Client #11 was admitted on April 28, 2023 and discharged on September 27, 2023. The was no documentation that an aftercare plan was developed with the client. This is a repeat citation from the March 15, 2023 licensing process. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility shall maintain a complete client record for each client which shall include aftercare plans and will be developed with the client prior to discharge and signed by the client. For the next 60 days, the Program Director will audit five charts per week to confirm that they contain aftercare plans which were developed prior to discharge and signed by the client. The Program Director will conduct quarterly audits to ensure that aftercare plans were developed prior to discharge and were signed by the client. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department. A plan of correction for ensuring that the project obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that includes what information is to be disclosed was submitted and approved by the Department for the March 25, 2022 and March 15, 2023 annual licensing inspections. Completing and documenting an informed and voluntary consent to release information containing what information could be disclosed was again found to be a deficiency in the February 6, 2024 licensing inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to comply with plans of correction that were approved by the Department. Over the next 90 days the Campus Director will review the Plan of Correction to ensure compliance.
Ongoing: The Campus Director will conduct
quarterly reviews of the Plan of Correction to |