INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on May 22, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of seven client records on May 22, 2018, the facility failed to document in seven of seven records reviewed, that the program may not discriminate in the provision of services based on ethnicity, marital status, sexual orientation, handicap or religion.
These findings were discussed with Facility staff during the inspection.
|
Plan of Correction
Verbiage was added to the facilities Client Rights Form used. The first sentence of the Client Rights form has been update to reflect the following:
"All individuals who apply for services, regardless of sex, race, age, color, creed, financial status, ethnicity, marital status, sexual identity, handicap, religion or national origin, are assured that their lawful rights as Clients shall be guaranteed and protected" |
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(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
|
Observations
Based on a review of seven client records on May 22, 2018, the facility failed to document written acknowledgement by clients that they had been notified of all their rights.
The Client Rights Form in client records # 1 - 7 failed to include that the clients have the right to request the correction of irrelevant and /or out dated information in their records.
These findings were reviewed with Faciltiy staff during the inspection.
|
Plan of Correction
Correct verbiage added to the facility Notce of Privacy Practices form. Under the Your Rights Section, Ask us to correct your medical record, verbiage was added to the form below:
"You can ask us to correct health information about you that you think is incorrect, incomplete, irrelavant or outdated. Ask us how to do this." |
709.93(a) 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:
|
Observations
Based on a review of seven client records on May 22, 2018, the facility failed to document case consultation notes and follow-up in one of one client record where applicable.
Client # 7 was admitted into treatment on January 17, 2018 and was discharged on April 12, 2018. There was no documentation of case consults or follow-up in the client record.
The findings were reviewed with facility staff during the inspection.
|
Plan of Correction
Staff education took place on 7/2/2018 which included re-education on case consultation form. Within the re-education new clinical policy was implemented to complete case consultations for each client within 30 days of the client being admitted to treatment discussing client progress in treatment any barriers that may have come up in treatment and/or documentation of scheduled family sessions, or any treatment changes.
-A New Audit of case consultations was implemented on 7/2/2018. There will be a monthly audit of case consultations included in the monthly chart audit of active clients done by the facility director to ensure the deficit does not reoccur. |