INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 28, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Open Arms Recovery Center 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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709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of seven client records on July 28,2021, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in one of seven client records reviewed. The consent must be in writing and include that a copy of a client consent shall be offered to the client and a copy maintained in the client record.
Client # 2 was admitted on December 29, 2020 and was a still current at the time of the inspection. Informed and voluntary consents to probation, an attorney, an insurance provider, a laboratory, two medical providers, two drug and alcohol providers and an emergency contact did not include whether the client was offered a copy of the consent.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will ensure that client consents continue to be properly filled out. Instead of only initialing whether they want a copy of the consent, clients will be instructed to put a check mark in the yes or no box. Weekly chart audits, conducted by the Clinical Supervisor will ensure adherence. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of seven client records on July 28, 2021, the facility failed to document follow-up information in two out of three applicable client records.
Client #5 was admitted on October 28, 2020 and was discharged on January 26, 2021. There was no documentation of follow-up being completed.
Client #6 was admitted on November 11, 2020 and was discharged on April 14, 2021. There was no documentation of follow-up being completed.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
On July 28, 2021, Clinical Supervisor, Director of Operations and Facility Director met with Counselor who had client #5 and #6 on their caseload and retrained to assure proper discharge protocol is being followed. Counselor had omitted the final step to task front office to send the follow up 30 days from the date of discharge. Clinical Supervisor, Director of Operations and Office Coordinator will work together to conduct discharge audits upon each client discharge. Counselor has been retrained in proper discharge procedures and will task front office to send 30 day follow up. |