INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 9, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Licensure Programs. 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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705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on the review of fire drill logs, the facility failed to conduct fire drills on different days of the week and at different times of the day. The fire drills from March 2021 through July 2021 were done on the first day of the month at noon.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Executive director will ensure that fire drills will begin to be completed on different days of the month at various times. For instance, one month may occur on the 2nd at 1pm. The following month may occur on the 14th at 3pm. |
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on the review of the facility's policy and procedures manual, the facility failed to document via signature that the project director annually updated the manual.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Executive director will prepare a signature page to be placed at the beginning of the manual for staff to sign acknowledging that they have reviewed all project policies and procedures annually. |
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 a review of client records, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5(b) for releases of information in four out of seven records reviewed. The informed and voluntary consent forms permitted the release of legal status, aftercare recommendations, discharge planning and discharge summary to the funding source.
Client #3 was admitted on June 8, 2021 and was still active at the time of the inspection. The consent form was dated June 30, 2021.
Client #5 was admitted on February 25, 2020 and was still active at the time of the inspection. The consent form was dated June 21, 2021.
Client #6 was admitted on March 12, 2020 and was still active at the time of the inspection. The consent form was dated June 8, 2021.
Client #7 was admitted on March 12, 2020 and was still active at the time of the inspection. The consent form was dated June 1, 2021.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Executive director will ensure that all disclosures of client identifying information are kept within the limits established by 4 pa. Code 255.5(b) for releases of information.
Currently, the form for disclosures allows the options of disclosures for the release of legal status, aftercare recommendations, discharge planning and discharge summary to the funding source.
Executive director will coordinate with the EHR (Kipu) to delete all options for disclosure beyond the limits established by 4 Pa. Code 255.5(b) for releases of information.
Executive director will also review with staff the limits established by 4 Pa. Code 255.5(b)regularly during staff supervisions.
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709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on the review of client records, the facility failed to document a completed informed and voluntary consent to release information form in six out of seven records reviewed. The consent forms did not have a dated client signature.
Client #2 was admitted June 8, 20201 and was still active at the time of the inspection. The two consent forms were to a family member and a funding source.
Client #3 was admitted on June 8, 2021 and was still active at the time of the inspection. The two consent forms were to a family member and a funding source.
Client #4 was admitted on June 7, 2021 and was still active at the time of the inspection. The consent form was to a family member.
Client #5 was admitted on February 25, 2020 and was still active at the time of the inspection. The two consent forms were to a funding source and a family member.
Client #6 was admitted on March 12, 2020 and was still active at the time of the inspection. The two consent forms were to a funding source and a family member.
Client #7 was admitted on March 12, 2020 and was still active at the time of the inspection. The two consent forms were to a funding source and a family member.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Executive director will ensure that the facility completes informed and voluntary consent to release information forms in its entirety. Executive director will ensure that all consent forms have a dated client signature. Executive director will include this action in the admission checklist for staff. |
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 a review of client records, the facility failed to ensure that the client was made aware of their rights in four out of four records reviewed. The facility's client rights acknowledged by the client did not include the client's right to inspect their own records, the facility temporarily removing portions of the record with documentation of reasons for removing information.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Executive director will update the client rights documentation to include the client's right to inspect their own records and to inform the client of the facility's ability to temporarily remove portions of the record with documentation of reasons for removing information. |
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 a review of client records, the facility failed to ensure that the client was made aware of their rights in four out of four records reviewed. The facility's client rights acknowledged by the client did not include the client's right to appeal a decision limiting access to their records.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Executive director will update the client rights documentation to include the the client's right to appeal a decision limiting access to their records. |
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 a review of client records, the facility failed to ensure that the client was made aware of their rights in four out of four records reviewed. The facility's client rights acknowledged by the client did not include the client's right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Executive director will update the client rights documentation to include the client's right 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 a review of client records, the facility failed to ensure that the client was made aware of their rights in four out of four records reviewed. The facility's client rights acknowledged by the client did not include the client's right to submit rebuttal data or memoranda to their own records.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Executive director will update the client rights documentation to includethe client's right to submit rebuttal data or memoranda to their own records.
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709.92(a) 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:
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Observations
Based on a review of client records, the facility failed to develop an individual treatment and rehabilitation plan with the client, as the record did not include a comprehensive treatment plan in two out of four records reviewed.
Client #1 was admitted on May 26, 2021 and was still active at the time of the inspection.
Client #2 was admitted on June 8, 2021 and was still active at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Executive director will ensure that a client's comprehensive treatment plan is completed with the client by the conclusion of their first individual session and/or within 1 week of admission. |
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 a review of client records, the facility failed to ensure that the clients received counseling services according to their individual comprehensive treatment plan in seven out of seven records reviewed.
Client #1 was admitted on May 26, 2021 and was still active at the time of the inspection. A progress note dated May 26, 2021 indicated group therapy 3x/weekly and individual therapy weekly. During the week of May 30-June 5, the client had group therapy on May 31 and June 3, 2021. The week of June 13-19, the client had group therapy on June 16 and 17, 2021.
Client #2 was admitted on June 8, 2021 and was still active at the time of the inspection. A progress note dated June 15, 2021 indicated group therapy 3x/week and individual therapy weekly. There was no documentation of group sessions after June 30, 2021.
Client #3 was admitted on June 8, 2021 and was still active at the time of the inspection. A progress note dated June 8, 2021 indicated group sessions 3x/week and individual sessions weekly. There was no documentation of group sessions after July 1, 2021.
Client #4 was admitted on June 7, 2021 and was still active at the time of the inspection. A progress note dated June 9, 2021 indicated group sessions 3x/week and individual sessions weekly. There was no documentation of group sessions after June 1, 2021.
Client #5 was admitted on February 25, 2020 and was still active at the time of the inspection. A progress note on March 20, 2021 indicated weekly individual sessions. There was no documentation of individual sessions between March 21 and April 2, 2021.
Client #6 was admitted on March 12, 2020 and was still active at the time of the inspection. A progress note dated March 12, 2021 indicated group therapy 3x/week and individual sessions weekly. There was no documentation of individual sessions between March 13 and March 26, 2021 and no sessions occurred after June 18, 2021.
Client #7 was admitted on March 12, 2020 and was still active at the time of the inspection. A progress note dated March 25, 2021 indicated group sessions 3x/week and individual sessions weekly. There was no documentation of individual sessions between May 14 - June 9, 2021 and no sessions after June 25, 2021. In addition, there were no group sessions after June 7, 2021.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Executive director will ensure that the clients received counseling services according to their individual comprehensive treatment plan. For instance, if the client is recommended for three groups and one individual weekly, three groups and one individual session will be had and documented in client's chart. |