INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 28, 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 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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709.28 (c) 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.
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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 contained in the client record in client records # 2 and 3.
Client # 2 was admitted on May 17, 2023 and was still active at the time of the inspection. A review of client records and discussion with facility administration indicated funding was being provided to the client. There was not an informed and voluntary consent from the client for the disclosure of information in the client record to a funding source.
Client # 3 was admitted on April 14, 2023 and was still active at the time of the inspection. A review of client records and discussion with facility administration indicated funding was being provided to the client. There was not an informed and voluntary consent from the client for the disclosure of information in the client record to a funding source.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director has created a Release of Information Form specifically designed to capture the informed and voluntary consent from clients for the disclosure of information in the client record to a funding source. This form will be included with all other admission paperwork required by clients to be completed prior to any services rendered and/or services billed. |
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 seven of seven 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 to inspect their own records and that 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.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director has updated the pre-existing Client Rights form to include all missing components discussed during this audit. This includes the following information:
Documentation of written acknowledgment by the client that the client had been made aware of their rights to inspect their own records and that 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. |
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 seven of seven 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 to appeal a decision limiting access to their records to the director.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director has updated the pre-existing Client Rights form to include all missing components discussed during this audit. This includes the following additional information:
Documentation of written acknowledgment by the client that the client had been made aware of their rights to appeal a decision limiting access to their records to the director.
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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 seven of seven 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 to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director has updated the pre-existing Client Rights form to include all missing components discussed during this audit. This includes the following additional information:
Documentation of written acknowledgment by the client that the client had been made aware of their rights to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records. |
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 seven of seven 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 to submit rebuttal data or memoranda to their own records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive director has updated the pre-existing Client Rights form to include all missing components discussed during this audit. This includes the following additional information:
documentation of written acknowledgment by the client that the client had been made aware of their rights to submit rebuttal data or memoranda to their own records. |
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 three of six applicable client records reviewed, the facility failed to provide treatment and rehabilitation updates in accordance with the facility policy and procedure manual. The facility policy and procedure indicate treatment and rehabilitation updates provide completion of treatment goals and the addition of new goals.
Client # 1 was admitted on September 7, 2022 and was still active at the time of the inspection. Treatment and rehabilitation updates occurred on October 13, 2022, November 18, 2022, January 18, 2023, March 17, 2023, and May 17, 2023. Each treatment and rehabilitation plan update repeated the same verbiage and did not update completion of goals or the addition of any new goals.
Client # 3 was admitted on April 14, 2023 and was still active at the time of the inspection. A treatment and rehabilitation update occurred on May 23, 2023. The treatment and rehabilitation plan update repeated the same verbiage of the comprehensive treatment plan developed on April 14, 2023 and did not update completion of goals or the addition of any new goals.
Client # 6 was admitted on January 26, 2023 and was discharged May 18, 2023. Treatment and rehabilitation updates occurred on May 23, 2023. Treatment and rehabilitation updates occurred on January 26, 2023, March 21, 2023. Each treatment and rehabilitation plan update repeated the same verbiage and did not update completion of goals or the addition of any new goals.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the April 7, 2023 annual licensing inspection.
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Plan of Correction
The Executive Director has ceased the use of the Wiley Treatment Plans provided by the EHR. Moving forward, templates for treatment plans will not be used in order to ensure that treatment plans are unique and tailored to the client. This ensures that the same verbiage is not used repeatedly.
In addition, a new form, the "Treatment Plan Review Form", will be utilized to update the status and/or completion of goals. This form also includes information related to adding new goals. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on one of three applicable client records reviewed, the facility failed to provide a discharge summary in accordance with the facility policy and procedure manual. The policy and procedure manual indicates a discharge summary be completed within one week of discharge.
Client # 7 was admitted on August 31, 2022 and was discharged on November 15, 2022. The discharge summary was due to be completed no later than November 22, 2022 however, the discharge summary was not completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This client's discharge was not completed due to oversight and human error. Executive Director will be more diligent about revisiting individuals suspended in the system when in rehab or jail so as to remember to discharge if and when appropriate.
To that end, ED will place a reminder in clients' charts when they are suspended in the system in order to be flagged when approaching the end of their suspended time, in order to d/c in a timely manner, if necessary.
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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 one of two applicable client records reviewed, the facility failed to provide a follow-up information in accordance with the facility policy and procedure manual. The policy and procedure manual indicates a follow-up be completed within 120 days of discharge.
Client # 7 was admitted on August 31, 2022 and was discharged on November 15, 2022. The follow-up was due to be completed no later than March 15, 2023; however, the follow-up was not completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director will utilize an alert system within the EHR regarding the due date for follow-up to be completed. At 90 days post-discharge, the system will provide an alert to remind users to complete follow-up, if one has not already been completed by this time. This will ensure that these are completed by the expected due dates as outlined in the facility policy and procedure manual.
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709.94(c) LICENSURE Project management services
709.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based on a physical plant inspection, the facility failed to provide a telephone number shall be displayed conspicuously to the general public for emergency purposes.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director has added a telephone number to the information conspicuously displayed to the general public for emergency purposes. |