INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on March 9, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, Colonial Park Intensive Outpatient Program, LLC. 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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705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on a physical plant inspection, the facility failed to ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed. A fire exit stairway in the rear of the office was obstructed with storage from the office space below.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive director will contact the facility landlord and request that the landlord speak with staff from the business below to clean the hallway.
At this time, staff from the business below have removed all items from the stairwell and hallway as of March 31st, 2021. Documentation available upon request.
Executive director will also check the stairwell regularly in order to ensure that stairways, hallways, and exits from rooms are not obstructed.
Executive director will communicate with staff below and landlord should this occur again. |
705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection, the facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The fire extinguisher in the rear of the office expired in March 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive director will contact the facility landlord and request a new fire extinguisher that is current and in compliance. As of March 31, 2021, this request has been completed; the fire extinguisher has been exchanged for a new fire extinguisher with a date of 2022. Documentation available upon request. Also, during monthly fire drills, the executive director will routinely check that the extinguisher remains in compliance. Executive director will include this in all future staff training.
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709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on three of three client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the name of the person, agency or organization to whom disclosure is made.
Client # 1 was admitted on December 2, 2020 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information signed and dated on March 6, 2021 did not include the name of the person, agency, or organization to whom disclosure is made.
Client # 2 was admitted on October 2, 2020 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information signed and dated on March 6, 2021 did not include the name of the person, agency, or organization to whom disclosure is made.
Client # 3 with an unknown admit date but was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information signed and dated on March 6, 2021 did not include the name of the person, agency, or organization to whom disclosure is made.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive director will ensure the facility obtains informed and voluntary consent from the client for the disclosure of information to include the name of the person, agency or organization to whom disclosure is made.
This will be done by any future clinicians and/or the executive director during the intake session. Executive director has revised the previous disclosure forms to capture these details.
The executive director is currently responsible for this correction as the only clinician working in this facility at this time. Executive director will include this in all future staff orientations and training. |
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 three of three 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 # 1 was admitted on December 2, 2020 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information signed and dated on March 6, 2021 did not include the purpose of the disclosure.
Client # 2 was admitted on October 2, 2020 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information signed and dated on March 6, 2021 did not include the purpose of the disclosure.
Client # 3 with an unknown admit date but was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information signed and dated on March 6, 2021 did not include the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive director will ensure that all parts of disclosures of information consents are completed upon admission. The facility will obtain an informed and voluntary consent from the client for the disclosure of information to include the purpose of the disclosure.
Executive director has revised the previous disclosure forms to capture these details. The executive director is currently responsible for this correction as the only clinician working in this facility at this time. Executive director will include this in all future staff orientations and training.
Executive director has also developed a checklist for staff to utilize during the intake process to ensure that all documents have been reviewed with clients and signed. Executive director will audit the client's chart immediately after admission and monthly moving forward to ensure all documents are included, signed, and completed in a timely manner. This will be completed by 5/12/2021. |
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 three of three client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include acknowledgement of the consent being offered to the client.
Client # 1 was admitted on December 2, 2020 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information signed and dated on March 6, 2021 did not include acknowledgement of the consent being offered to the client.
Client # 2 was admitted on October 2, 2020 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information signed and dated on March 6, 2021 did not include acknowledgement of the consent being offered to the client.
Client # 3 with an unknown admit date but was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information signed and dated on March 6, 2021 did not include acknowledgement of the consent being offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive director has reviewed and added the option for clients to decline or accept a copy of each document. Either option requires a client's initial and/or signature. Doing so will ensure that the consent was reviewed with the client and acknowledges that the clinician offered the client copies. Accepting or refusing copies will be noted in the clients' admission note. Clients will be informed that they are able to access and retrieve copies at any time. The executive director is currently responsible for this correction as the only clinician working in this facility at this time. Executive director will include this in all future staff orientations and training. Executive director has also developed a checklist for staff to utilize during the intake process to ensure that all documents have been fully reviewed with clients and signed. Executive director will audit the client's chart immediately after admission and monthly moving forward to ensure all documents are included, signed, and completed in a timely manner. This will be completed by 5/12/2021. |
709.30 (1) 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.
(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.
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Observations
Based on three of three client records reviewed, the acknowledgement by clients that they were notified of their rights did not occur at admission or within a reasonable timeframe.
Client # 1 was admitted on December 2, 2020 and was still active at the time of the inspection. The client rights acknowledgement form was signed by the client on March 6, 2021
Client # 2 was admitted on October 2, 2020 and was still active at the time of the inspection. The client rights acknowledgement form was signed by the client on March 6, 2021
Client # 3 with an unknown admit date but was admitted in 2020 and was still active at the time of the inspection. The client rights acknowledgement form was signed by the client on March 6, 2021
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive director will ensure that all clients are informed of their client rights upon the beginning of the admission process. A form has been devised for clients to sign in which he/she will acknowledge that they have reviewed and understand their client rights with their intake clinician. Executive director will also ensure that each admission has an admission note in their chart regarding reviewing client rights. Executive director has also developed a checklist for staff to utilize during the intake process to ensure that all documents have been fully reviewed with clients and signed. Executive director will audit the client's chart immediately after admission and monthly moving forward to ensure all documents are included, signed, and completed in a timely manner. This will be completed by 5/12/2021. |
709.31 (b) LICENSURE Data collection system
§ 709.31. Data collection system.
(b) The recordkeeping system must allow for the identification of clients' admissions and discharges within a specific time period.
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Observations
Based on an onsite inspection, the facility failed to provide identification of clients' admission and discharge dates. The facility was unable to provide accurate admit dates for the current active clients.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive director will ensure that admission dates and discharge dates are recorded accurately. The executive director has agreed to work with a new electronic health record that is capable of capturing this information and will help to keep track of these dates. Admission dates and discharge dates will also be noted in an admission note and discharge notes as well as client face sheets. Executive director was also able to locate client files from before this director assumed the facility, allowing for accurate admission and discharge dates to be accessed. The executive director is currently responsible for this correction as the only clinician working in this facility at this time. Executive director will include this in all future staff orientations and training. This will be completed by 5/12/2021. |
709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on three of three client records reviewed, the facility failed to provide documentation of disclosure to the client of criteria for admission, treatment, completion and discharge at intake.
Client # 1 was admitted on December 2, 2020 and was still active at the time of the inspection. The criteria for admission, treatment, completion and discharge documentation was not signed by the client until March 6, 2021.
Client # 2 was admitted on October 2, 2020 and was still active at the time of the inspection. The criteria for admission, treatment, completion and discharge documentation was not signed by the client until March 6, 2021.
Client # 3 was admitted in 2020 and was still active at the time of the inspection. The criteria for admission, treatment, completion and discharge documentation was not signed by the client until March 6, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility will provide documentation of disclosure to the client of criteria for admission, treatment, completion and discharge at intake. Executive director will also ensure that each admission has an admission note in their chart regarding that consent forms were reviewed, signed, and copies were offered to the client. Executive director has also developed a checklist for staff to utilize during the intake process to ensure that all documents have been fully reviewed with clients and signed. Executive director will audit the client's chart immediately after admission and monthly moving forward to ensure all documents are included, signed, and completed in a timely manner. This will be completed by 5/12/2021. |
709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
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Observations
Based on three of three client records reviewed, the facility failed to provide documentation of the client being oriented to the project to include a familiarization with the project policies during intake.
Client # 1 was admitted on December 2, 2020 and was still active at the time of the inspection. Client orientation to the project to include project policies was not documented until March 6, 2021.
Client # 2 was admitted on October 2, 2020 and was still active at the time of the inspection. Client orientation to the project to include project policies was not documented until March 6, 2021.
Client # 3 was admitted in 2020 and was still active at the time of the inspection. Client orientation to the project to include project policies was not documented until March 6, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive director has devised a handbook for clients to sign and to acknowledge, incorporating this information. Executive director has also devised a checklist to ensure that all required information is gathered. For instance, a checklist has been developed for admissions to ensure that this information is captured. Executive director has ensured that this documentation includes client orientation to the project and familiarization with the project policies during intake. This will also be documented in the client's admission note. New clients will be expected to attend an orientation session to review all policies, procedures, and guidelines. The executive director is currently responsible for this correction as the only clinician working in this facility at this time. Executive director will include this in all future staff orientations and training. Executive director will audit the client's chart immediately after admission and monthly moving forward to ensure all documents are included, signed, and completed in a timely manner. This will be completed by 5/12/2021. |
709.91(b)(2)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(ii) Hours of operation.
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Observations
Based on three of three client records reviewed, the facility failed to provide documentation of the client being oriented to the project to include a familiarization with the hours of operation during intake.
Client # 1 was admitted on December 2, 2020 and was still active at the time of the inspection. Client orientation to the project to include the hours of operation was not documented until March 6, 2021.
Client # 2 was admitted on October 2, 2020 and was still active at the time of the inspection. Client orientation to the project to include the hours of operation was not documented until March 6, 2021.
Client # 3 was admitted in 2020 and was still active at the time of the inspection. Client orientation to the project to include the hours of operation was not documented until March 6, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
9. Executive director has devised a handbook for clients to sign and to acknowledge, incorporating this information. Executive director has also devised a checklist to ensure that all required information is gathered. For instance, a checklist has been developed for admissions to ensure that this information is reviewed with clients. Executive director has ensured that this documentation includes client orientation to the project and familiarization with the project policies during intake such as hours of operation. This will also be documented in the client's admission note. New clients will be expected to attend an orientation session to review all policies, procedures, and guidelines. The executive director is currently responsible for this correction as the only clinician working in this facility at this time. Executive director will include this in all future staff orientations and training. This will be completed by 5/12/2021. |
709.91(b)(2)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iii) Fee schedule.
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Observations
Based on three of three client records reviewed, the facility failed to provide documentation of the client being oriented to the project to include a familiarization with the fee schedule during intake.
Client # 1 was admitted on December 2, 2020 and was still active at the time of the inspection. Client orientation to the project to include the fee schedule was not documented until March 6, 2021.
Client # 2 was admitted on October 2, 2020 and was still active at the time of the inspection. Client orientation to the project to include the fee schedule was not documented until March 6, 2021.
Client # 3 was admitted in 2020 and was still active at the time of the inspection. Client orientation to the project to include the fee schedule was not documented until March 6, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive director has devised a handbook for clients to sign and to acknowledge, incorporating this information. Executive director has also devised a checklist to ensure that all required information is gathered. For instance, a checklist has been developed for admissions to ensure that this information is reviewed with clients. Executive director has ensured that this documentation includes client orientation to the project and familiarization with the project policies during intake such as the Colonial Park IOP fee schedule. This will also be documented in the client's admission note. New clients will be expected to attend an orientation session to review all policies, procedures, and guidelines. The executive director is currently responsible for this correction as the only clinician working in this facility at this time. Executive director will include this in all future staff orientations and training. This will be completed by 5/12/2021.
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709.91(b)(2)(iv) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iv) Services provided.
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Observations
Based on three of three client records reviewed, the facility failed to provide documentation of the client being oriented to the project to include a familiarization with the services provided during intake.
Client # 1 was admitted on December 2, 2020 and was still active at the time of the inspection. Client orientation to the project to include the services provided was not documented until March 6, 2021.
Client # 2 was admitted on October 2, 2020 and was still active at the time of the inspection. Client orientation to the project to include the services provided was not documented until March 6, 2021.
Client # 3 was admitted in 2020 and was still active at the time of the inspection. Client orientation to the project to include the services provided was not documented until March 6, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive director has devised a handbook for clients to sign and to acknowledge, incorporating this information. Executive director has also devised a checklist to ensure that all required information is gathered. For instance, a checklist has been developed for admissions to ensure that this information is reviewed with clients. Executive director has ensured that this documentation includes client orientation to the project and familiarization with the project policies during intake. This will also be documented in the client's admission note. New clients will be expected to attend an orientation session to review all policies, procedures, and guidelines. The executive director is currently responsible for this correction as the only clinician working in this facility at this time. Executive director will include this in all future staff orientations and training. This will be completed by 5/12/2021.
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709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on two of three client records reviewed, the facility failed to provide documentation that a medical history was completed as part of the intake procedure.
Client # 2 was admitted on October 2, 2020 and was still active at the time of the inspection. A medical history was not documented until March 6, 2021.
Client # 3 was admitted in 2020 and was still active at the time of the inspection. A medical history was not documented until March 6, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive director has devised a handbook for clients to sign and to acknowledge, incorporating this information. Executive director has also devised a checklist to ensure that all required information is gathered. For instance, a checklist has been developed for admissions to ensure that this information is reviewed with clients. Executive director has ensured that this documentation includes client orientation to the project and familiarization with the project policies during intake.
The new EHR is also designed to better capture all histories and assessments.
The executive director is currently responsible for this correction as the only clinician working in this facility at this time. Executive director will include this in all future staff orientations and training. This will be completed by 5/12/2021.
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709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on two of three client records reviewed, the facility failed to provide documentation that a drug and alcohol history was completed as part of the intake procedure.
Client # 2 was admitted on October 2, 2020 and was still active at the time of the inspection. A drug and alcohol history was not documented until March 6, 2021.
Client # 3 was admitted in 2020 and was still active at the time of the inspection. A drug and alcohol history was not documented until March 6, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive director has devised a handbook for clients to sign and to acknowledge, incorporating this information. Executive director has also devised a checklist to ensure that all required information is gathered. For instance, a checklist has been developed for admissions to ensure that this information is reviewed with clients. Executive director has ensured that this documentation includes assessment information such as a drug and alcohol history. The new EHR system allows for easy collection of this data. The executive director is currently responsible for this correction as the only clinician working in this facility at this time. Executive director will include this in all future staff orientations and training. This will be completed by 5/12/2021. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on two of three client records reviewed, the facility failed to provide documentation that a personal history was completed as part of the intake procedure.
Client # 2 was admitted on October 2, 2020 and was still active at the time of the inspection. A personal history was not documented until March 6, 2021.
Client # 3 was admitted in 2020 and was still active at the time of the inspection. A personal history was not documented until March 6, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive director has devised a handbook for clients to sign and to acknowledge, incorporating this information. Executive director has also devised a checklist to ensure that all required information is gathered. For instance, a checklist has been developed for admissions to ensure that this information is reviewed with clients. Executive director has ensured that this documentation includes documentation of histories which include personal history. Executive director will ensure that all assessments and documentation of history is completed at each intake session. The new EHR system implemented also allows for easy collection of this data. The executive director is currently responsible for this correction as the only clinician working in this facility at this time. Executive director will include this in all future staff orientations and training. This will be completed by 5/12/2021. |
709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on three of three client records reviewed, the facility failed to document a consent to treatment during intake.
Client # 1 was admitted on December 2, 2020 and was still active at the time of the inspection. A consent to treatment was not acknowledged by the client until January 28, 2021.
Client # 2 was admitted on October 2, 2020 and was still active at the time of the inspection. A consent to treatment was not acknowledged by the client until March 6, 2021.
Client # 3 was admitted in 2020 and was still active at the time of the inspection. A consent to treatment was not acknowledged by the client until March 6, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive director will ensure the facility obtains consent for treatment from the client immediately upon admission. This will be done by any future clinicians and/or the executive director during the intake session. The executive director is currently responsible for this correction as the only clinician working in this facility at this time. Executive director will include this in all future staff orientations and training. Executive director has also developed a checklist for staff to utilize during the intake process to ensure that all documents have been reviewed with clients and signed. Executive director will audit the client's chart immediately after admission and monthly moving forward to ensure all documents are included, signed, and completed in a timely manner. This will be completed by 5/12/2021. |
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 two of three client records reviewed, the facility failed to document a psychosocial evaluation during intake.
Client # 2 was admitted on October 2, 2020 and was still active at the time of the inspection. There was no documentation of a psychosocial evaluation in the client record.
Client # 3 was admitted on October 2, 2020 and was still active at the time of the inspection. There was no documentation of a psychosocial evaluation in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive director has ensured that client documentation includes documentation of histories which include medical history, drug and alcohol history, biopsychosocial assessments, interpretive summaries, etc. Executive director will review all assessments and summaries. The new EHR system implemented also allows for easy collection of this data. The executive director is currently responsible for this correction as the only clinician working in this facility at this time. Executive director will include this in all future staff orientations and training. This will be completed by 5/12/2021. |
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 two of three applicable client records reviewed, the facility failed to provide treatment and rehabilitation plan updates to occur at least every sixty days.
Client # 1 was admitted on December 2, 2020 and was still active at the time of the inspection. The comprehensive treatment and rehabilitation plan was developed on December 2, 2020. A treatment plan update was due to occur no later than February 2, 2021 however, there was no update documented in the client record.
Client # 2 was admitted on October 2, 2020 and was still active at the time of the inspection. The comprehensive treatment and rehabilitation plan was developed on October 2, 2020. A treatment plan update was due to occur no later than December 2, 2020 and February 2, 2021 however, there was no update documented in the client record.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the annual renewal inspection conducted on June 11, 2019.
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Plan of Correction
Executive director will ensure that initial treatment plans are completed during the intake session. Executive director will also ensure that treatment plan updates are done in compliance with company policy and DDAP regulations. The new EHR program provides a tickler to remind staff of upcoming treatment plan updates, case consults, etc. Executive director will also monitor compliance regarding treatment plans. he executive director is currently responsible for this correction as the only clinician working in this facility at this time. Executive director will include this in all future staff orientations and training. This will be completed by 5/12/2021. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on two of three applicable client records reviewed, the facility failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan.
Client # 1 was admitted on December 2, 2020 and was still active at the time of the inspection. The comprehensive treatment and rehabilitation plan was developed on December 2, 2020 that indicated Individual sessions weekly and three groups weekly. A review of client records and record of service did not document any individual sessions.
Client # 2 was admitted on October 2, 2020 and was still active at the time of the inspection. The comprehensive treatment and rehabilitation plan was developed on October 2, 2020 that indicated Individual sessions weekly and three groups weekly. A review of client records and record of service did not document any individual sessions.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive director will assure that counseling services are provided according to the individual treatment and rehabilitation plan. Executive director will ensure that clients are receiving all necessary care and are compliant with treatment recommendations. For instance, if IOP is recommended, the client is expected to adhere to a schedule of Monday, Wednesday, and Thursday from 6pm to 9pm as this will be outlined in his or her treatment plan. Executive director will ensure that progress notes are written and submitted within 24 hours of the provided services. Executive director will also ensure that all treatment goals and interventions match the services provided by the clinician. Executive director will also ensure that all client documentation is completed in a timely manner consistent with DDAP regulations. The executive director is currently responsible for this correction as the only clinician working in this facility at this time. Executive director will include this in all future staff orientations and training. This will be completed by 5/12/2021. |
709.93(a)(4) 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:
(4) Referral contact.
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Observations
Based on three of three client records reviewed, the facility failed to provide a complete client record to include a referral contact.
Client # 1 was admitted on December 2, 2020 and was still active at the time of the inspection. Client records did not provide a referral contact.
Client # 2 was admitted on October 2, 2020 and was still active at the time of the inspection. Client records did not provide a referral contact.
Client # 3 was admitted in 2020 and was still active at the time of the inspection. Client records did not provide a referral contact.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive director will ensure that client records provide a referral source at intake. Referral source will be included in admission note as well as client's facesheet. The executive director is currently responsible for this correction as the only clinician working in this facility at this time. Executive director will include this in all future staff orientations and training. This will be completed by 5/12/2021. |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on three of three client records reviewed, the facility failed to provide a complete client record to include progress notes for individual sessions. During the inspection process, the facility director was attempting to download progress notes from an outside resource.
Client # 1 was admitted on December 2, 2020 and was still active at the time of the inspection. Client records did not provide progress notes for individual sessions.
Client # 2 was admitted on October 2, 2020 and was still active at the time of the inspection. Client records did not provide progress notes for individual sessions.
Client # 3 was admitted in 2020 and was still active at the time of the inspection. Client records did not provide progress notes for individual sessions.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will be able to provide a complete and thorough client chart with all necessary documentation. Executive director will ensure that progress notes are documented for all individual sessions.
Executive director will also ensure that all treatment goals and interventions match the services provided by the clinician. The executive director is currently responsible for this correction as the only clinician working in this facility at this time. Executive director will include this in all future staff orientations and training. This will be completed by 5/12/2021. |