INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 5, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Colonial House, 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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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on two of three applicable client records reviewed, the facility failed to provide documentation of the emergency contact being notified when a client leaves against medical advice in accordance with the facility policy and procedure manual. The facility policy and procedure indicates the emergency contact be notified of the client leaving against medical advice immediately and documented in the client record.
Client # 1 was admitted on October 13, 2022 and was discharged on October 27, 2022. There was no documentation of the emergency contact being notified of the client leaving against medical advice in the client record.
Client # 5 was admitted on June 15, 2022 and was discharged on July 25, 2022. There was no documentation of the emergency contact being notified of the client leaving against medical advice in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director addressed the Clinical team in staff meetings on 05/10/2023 and 05/17/2023 regarding DDAP audit findings, specifically the failure of the Clinical team to adhere to the policy of notifying the emergency contact immediately that a client has left against medical advice and documenting it in the client record.
Clinical Supervisor will audit all AFA charts moving forward and ensure the EC has been notified in a timely manner. ED and CS will remind staff to abide by policy as stated when informed of an AFA discharge in the evenings or weekends. |
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 one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the specific information disclosed.
Client # 5 was admitted on June 15, 2022 and discharged on July 25, 2022. An informed and voluntary consent from the client for the disclosure of information dated July 14, 2022 to a referral did not provide the specific information that was to be disclosed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff training provided by Executive Director in staff meetings on 05/10/2023 and 05/17/2023 regarding the completion of consents, specifically, specific information disclosed.
Charts will be audited by Clinical Supervisor weekly and upon discharge to ensure compliance. |
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 two of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the purpose of the disclosure.
Client # 3 was admitted on October 14, 2022 and discharged on November 10, 2022. An informed and voluntary consent from the client for the disclosure of information dated October 14, 2022 to an acquaintance did not provide the purpose of the disclosure.
Client # 5 was admitted on June 15, 2022 and discharged on July 25, 2022. An informed and voluntary consent from the client for the disclosure of information dated July 14, 2022 to a referral did not provide the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff training provided by Executive Director in staff meetings on 05/10/2023 and 05/17/2023 regarding the completion of consents, specifically, the purpose of disclosure.
Charts will be audited by Clinical Supervisor weekly and upon discharge to ensure compliance. |
709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the date, event or condition upon which the consent will expire.
Client # 5 was admitted on June 15, 2022 and discharged on July 25, 2022. An informed and voluntary consent from the client for the disclosure of information dated July 14, 2022 to a referral did not include the date, event or condition upon which the consent will expire.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff training provided by Executive Director in staff meetings on 05/10/2023 and 05/17/2023 regarding the completion of consents, specifically, the date, event or condition upon which the consent will expire.
Charts will be audited by Clinical Supervisor weekly and upon discharge to ensure compliance. |
709.30 (2) 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.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on two of six applicable client records reviewed, the facility failed to provide documentation of written acknowledgment by the client that the client had been made aware of their rights on the basis of discrimination of services to include ethnicity, marital status, sexual orientation, handicap, or religion in client record # ' s 6, and 7.
Client # 6 was admitted on December 29, 2022 and discharged on March 13, 2023. Ethnicity, marital status, sexual orientation, handicap, or religion acknowledgement was not documented in the client record.
Client # 7 was admitted on January 3, 2023 and discharged on January 27, 2023. Ethnicity, marital status, sexual orientation, handicap, or religion acknowledgement was not documented in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director replaced the Client Rights form in the EMR with an updated one, including the following information:
1. A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
2. The facility may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
3. Clients have the right to inspect their own records. The executive director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
4. Clients have the right to appeal a decision limiting access to their records to the director.
5. Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
6. Clients have the right to submit rebuttal data or memoranda to their own records.
All clients sign the Client Rights form upon admission. All clients receive a copy of the Client Rights as included in the Client Handbook.
Executive Director permanently replaced the Client Rights information in the EMR with the information above which all clients will sign. Admissions Coordinator will ensure all new clients sign that they have reviewed their Client Rights as stated above and that they received a copy of the Client Handbook upon admission, including the Client Rights as stated above. |
709.30 (3) 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.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on six of six applicable client records reviewed, the facility failed to ensure that there was appropriate documentation of written acknowledgment by the client that the client had been made aware of their rights to include the right to inspect their own records, the project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client, and reasons for removing sections shall be documented in the record in client records # 6, 7.
Documentation of written acknowledgment by the client for reasons for removing sections shall be documented in the record was missing for clients # 1, 2, 3 and 5.
Client # 1 was admitted on October 13, 2022 and was discharged on October 27, 2022.
Client # 2 was admitted on September 20, 2022 and discharged December 12, 2022.
Client # 3 was admitted on October 14, 2022 and discharged on November 10, 2022.
Client # 5 was admitted on June 15, 2022 and discharged on July 25, 2022.
Client # 6 was admitted on December 29, 2022 and discharged on March 13, 2023.
Client # 7 was admitted on January 3, 2023 and discharged on January 27, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director replaced the Client Rights form in the EMR with an updated one, including the following information:
1. A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
2. The facility may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
3. Clients have the right to inspect their own records. The executive director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
4. Clients have the right to appeal a decision limiting access to their records to the director.
5. Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
6. Clients have the right to submit rebuttal data or memoranda to their own records.
All clients sign the Client Rights form upon admission. All clients receive a copy of the Client Rights as included in the Client Handbook.
Executive Director permanently replaced the Client Rights information in the EMR with the information above which all clients will sign. Admissions Coordinator will ensure all new clients sign that they have reviewed their Client Rights as stated above and that they received a copy of the Client Handbook upon admission, including the Client Rights as stated above. |
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
Based on two of six applicable client records reviewed, the facility failed to provide documentation of written acknowledgment by the client that the client had been made aware of their right to appeal a decision limiting access to their records to the director in client records # 6, and 7.
Client # 6 was admitted on December 29, 2022 and discharged on March 13, 2023. The right to appeal a decision limiting access to their records to the director was not documented in the client record.
Client # 7 was admitted on January 3, 2023 and discharged on January 27, 2023. The right to appeal a decision limiting access to their records to the director was not documented in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director replaced the Client Rights form in the EMR with an updated one, including the following information:
1. A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
2. The facility may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
3. Clients have the right to inspect their own records. The executive director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
4. Clients have the right to appeal a decision limiting access to their records to the director.
5. Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
6. Clients have the right to submit rebuttal data or memoranda to their own records.
All clients sign the Client Rights form upon admission. All clients receive a copy of the Client Rights as included in the Client Handbook.
Executive Director permanently replaced the Client Rights information in the EMR with the information above which all clients will sign. Admissions Coordinator will ensure all new clients sign that they have reviewed their Client Rights as stated above and that they received a copy of the Client Handbook upon admission, including the Client Rights as stated above. |
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
Based on two of six applicable client records reviewed, the facility failed to provide documentation of written acknowledgment by the client that the client had been made aware of their right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records in client records # 6, and 7.
Client # 6 was admitted on December 29, 2022 and discharged on March 13, 2023. The right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records was not documented in the client record.
Client # 7 was admitted on January 3, 2023 and discharged on January 27, 2023. The right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records was not documented in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director replaced the Client Rights form in the EMR with an updated one, including the following information:
1. A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
2. The facility may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
3. Clients have the right to inspect their own records. The executive director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
4. Clients have the right to appeal a decision limiting access to their records to the director.
5. Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
6. Clients have the right to submit rebuttal data or memoranda to their own records.
All clients sign the Client Rights form upon admission. All clients receive a copy of the Client Rights as included in the Client Handbook.
Executive Director permanently replaced the Client Rights information in the EMR with the information above which all clients will sign. Admissions Coordinator will ensure all new clients sign that they have reviewed their Client Rights as stated above and that they received a copy of the Client Handbook upon admission, including the Client Rights as stated above. |
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
Based on two of six applicable client records reviewed, the facility failed to provide documentation of written acknowledgment by the client that the client had been made aware of their right to submit rebuttal data or memoranda to their own records in client records # 6, and 7.
Client # 6 was admitted on December 29, 2022 and discharged on March 13, 2023. The right to submit rebuttal data or memoranda to their own records was not documented in the client record.
Client # 7 was admitted on January 3, 2023 and discharged on January 27, 2023. The right to submit rebuttal data or memoranda to their own records was not documented in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director replaced the Client Rights form in the EMR with an updated one, including the following information:
1. A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
2. The facility may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
3. Clients have the right to inspect their own records. The executive director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
4. Clients have the right to appeal a decision limiting access to their records to the director.
5. Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
6. Clients have the right to submit rebuttal data or memoranda to their own records.
All clients sign the Client Rights form upon admission. All clients receive a copy of the Client Rights as included in the Client Handbook.
Executive Director permanently replaced the Client Rights information in the EMR with the information above which all clients will sign. Admissions Coordinator will ensure all new clients sign that they have reviewed their Client Rights as stated above and that they received a copy of the Client Handbook upon admission, including the Client Rights as stated above. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on two of five applicable client records reviewed, the facility failed to provide an individual treatment and rehabilitation plan developed with the client to include the type and frequency of treatment and rehabilitation services.
Client # 6 was admitted on December 29, 2022 and discharged on March 13, 2023. A comprehensive treatment and rehabilitation plan was developed with the client on March 10, 2023. There was no documentation of type and frequency of services.
Client # 7 was admitted on January 3, 2023 and discharged on January 27, 2023. A comprehensive treatment and rehabilitation plan was developed with the client on March 9, 2023. There was no documentation of type and frequency of services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director met with the Clinical team on 05/10/2023 and Clinical staff were instructed to note type and frequency of services as "Group Therapy 5-7x/week" and "Individual Therapy 1x/week" on all treatment plans, as applicable.
Clinical team expressed understanding and has been implementing the suggested format, as evidenced by weekly chart audits by Clinical Supervisor.
Clinical Supervisor will audit all treatment plans for compliance weekly and upon discharge. |
709.53(a)(3) LICENSURE Records of Service
709.53. 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:
(3) Record of services provided.
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Observations
Based on five of seven client records reviewed, the facility failed to provide a complete client record to include a record of service that is reflective of the client's progress notes in client records # 1, 2, 3, 4, and 5.
Client # 1 was admitted on October 13, 2022 and was discharged on October 27, 2022.
A review of progress notes indicates individual and group sessions occurred. There was no documentation of a client record of service.
Client # 2 was admitted on September 20, 2022 and discharged December 12, 2022. A review of progress notes indicates individual and group sessions occurred. There was no documentation of a client record of service.
Client # 3 was admitted on October 14, 2022 and discharged on November 10, 2022.
A review of progress notes indicates individual and group sessions occurred. There was no documentation of a client record of service.
Client # 4 was admitted on April 8, 2022 and discharged June 28, 2022. A review of progress notes indicates individual and group sessions occurred. There was no documentation of a client record of service.
Client # 5 was admitted on June 15, 2022 and discharged on July 25, 2022. A review of progress notes indicates individual and group sessions occurred. There was no documentation of a client record of service.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director met with the Clinical team on 05/10/2023 and Clinical staff were instructed to note the services provided to a client on the record of service as they occur in paper charts.
Charts #1-5 were paper charts.
Currently we are utilizing an EMR which includes the record of service in a Clinical tab in the record.
Clinical Supervisor will audit all charts and ensure compliance with proper completion of record of services weekly and upon discharge. |