INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 29, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the 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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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 the client records, the facility failed to ensure that their data collection and recordkeeping system permitted for efficient retrieval of the data to measure the project's performance in relationship to assuring that the services provided to the clients meet the regulations.
The finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Colonial Park Intensive Outpatient Program, LLC. has begun to utilize the KIPU electronic healthcare system. The executive director and staff will receive training from Kipu staff to ensure that all users are adequately trained in data collection and recordkeeping. At this time, Executive Director has ensured that all previous documentation has been input into the new system and will continue to keep accurate and up-to-date information. These corrections will allow for the efficient retrieval of data needed to measure the project's performance in relation to its stated goals and objectives. |
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 a review of client records, the facility failed to document a medical history in the client record as of the date of the licensing inspection in three out of the seven records reviewed.
Client #2 was admitted to the facility on March 10, 2022 and was still active at the time of the inspection. A medical history was due no later than April 10, 2022 per the policy and procedures manual. There was no medical history documented in the record.
Client #4 was admitted to the facility on July 28, 2021 and discharged on October 6, 2021. A medical history was due no later than August 28, 2021 per the policy and procedures manual, however the medical history documented in the record did not have a date when completed.
Client #7 was admitted to the facility on January 10, 2022 and was discharged on April 15, 2022. A medical history was due no later than February 10, 2022 per the policy and procedures manual, however the medical history documented in the record did not have a date when completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Kipu staff will create a checklist/audit tool within the EHR to ensure that this information has been completed during the intake process. This checklist will need to be reviewed and signed by the facility director. The facility director will also work with KIPU staff to create a tickler in the system to keep track of documentation due dates. Kipu will also restrict access to other documentation, until all consent forms, assessments, and related intake documentation have been completed, ensuring the timely completion of the medical history assessments. |
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 a review of client records, the facility failed to document a drug and alcohol history in the client record as of the date of the licensing inspection in three out of the seven records reviewed.
Client #2 was admitted to the facility on March 10, 2022 and was still active at the time of the inspection. A drug and alcohol history was due no later than April 10, 2022 per the policy and procedures manual. There was no drug and alcohol history documented in the record.
Client #4 was admitted to the facility on July 28, 2021 and discharged on October 6, 2021. A drug and alcohol history was due no later than August 28, 2021 per the policy and procedures manual, however the drug and alcohol history documented in the record did not have a date when completed.
Client #7 was admitted to the facility on January 10, 2022 and was discharged on April 15, 2022. A drug and alcohol history was due no later than February 10, 2022 per the policy and procedures manual, however the drug and alcohol history documented in the record did not have a date when completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Kipu staff will create a checklist/audit tool within the EHR to ensure that this information has been completed during the intake process. This checklist will need to be reviewed and signed by the facility director. The facility director will also work with KIPU staff to create a tickler in the system to keep track of documentation due dates. Kipu will also restrict access to other documentation until all consent forms, assessments, and related intake documentation have been completed, ensuring the timely completion of the documentation of histories, including the drug and alcohol history. |
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 a review of client records, the facility failed to document a personal history in the client record as of the date of the licensing inspection in three out of the seven records reviewed.
Client #2 was admitted to the facility on March 10, 2022 and was still active at the time of the inspection. A personal history was due no later than April 10, 2022 per the policy and procedures manual. There was no personal history documented in the record.
Client #4 was admitted to the facility on July 28, 2021 and discharged on October 6, 2021. A personal history was due no later than August 28, 2021 per the policy and procedures manual, however the personal history documented in the record did not have a date when completed.
Client #7 was admitted to the facility on January 10, 2022 and was discharged on April 15, 2022. A personal history was due no later than February 10, 2022 per the policy and procedures manual, however the personal history documented in the record did not have a date when completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Kipu staff will create a checklist/audit tool within the EHR to ensure that this information has been completed during the intake process. This checklist will need to be reviewed and signed by the facility director. The facility director will also work with KIPU staff to create a tickler in the system to keep track of documentation due dates. Kipu will also restrict access to other documentation until all consent forms, assessments, and related intake documentation have been completed, ensuring the timely completion of the documentation of histories, including personal history.
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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 a review of client records, the facility failed to document a psychosocial evaluation in client records as of the date of the licensing inspection in three out of seven records reviewed.
Client #2 was admitted to the facility on March 10, 2022 and was still an active client at the time of the inspection. A psychosocial evaluation was due no later than April 10, 2022 per the policy and procedures manual. There was no psychosocial evaluation in the record.
Client #4 was admitted to the facility on July 28, 2021 and discharged on October 6, 2021. A psychosocial evaluation was due no later than August 28, 2021 per the policy and procedures manual; however the psychosocial evaluation dcoumented in the record did not have a date when completed.
Client # 7 was admitted to the facility on January 10, 2022 and was discharged on April 15, 2022. A psychosocial evaluation was due no later than February 10, 2022 per the policy and procedures manual; however the psychosocial evaluation documented in the record did not have a date when completed.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Executive Director and Kipu staff will create a checklist within the EHR to ensure that this information has been completed during the intake process. This checklist will need to be reviewed and signed by the facility director. The facility director will also work with KIPU staff to create a tickler in the system to keep track of documentation due dates, ensuring the timely completion of the documentation of psychosocial evaluations.
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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 support services in the individual treatment and rehabilitation plan in seven out of seven records reviewed.
The finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Executive Director has created a new required section within the treatment plan templates regarding support services. Executive Director will review the available resources and ensure that staff includes these services prior to signing as the Executive Director. This task will also be included in intake documentation. |
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 in four out of seven client records reviewed.
Client # 2 was admitted to the facility on March 10, 2022 and was still an active client at the time of the inspection. A treatment plan was completed on March 10, 2022. A treatment plan update was due no later than April 10, 2022 as per the policy and procedures manual; however the treatment plan documented in the record did not have a date when completed.
Client #3 was admitted to the facility on October 28, 20221 and was still active at the time of the inspection. A treatment plan update was completed on February 15, 2022 and the next update was due no later than April 15, 2022; however the treatment plan documented in the record was dated April 19, 2022. +
Client #4 was admitted to the facility on July 28, 2021 and discharged on October 6, 2021, A treatment plan was completed on August 4, 2021 and the next update was due no later than October 4, 2021; however the treatment plan documented in the record did not have a date when completed.
Client # 7 was admitted to the facility on January 10, 2022 and was discharged on April 15, 2022. A treatment plan was completed on January 10, 2022 and the next update was due no later than April 10, 2022; however the treatment plan documented in the file did not have a date when completed.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Executive Director will work with KIPU staff to create a tickler in the system to keep track of documentation due dates. These ticklers will exist for both staff and the Executive Director in order to ensure reviews and updates are completed every 60 days. |