INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 1, 2019 through October 2, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, STR Addiction Counseling, 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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709.23 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
The facility failed to document that the project director had prepared, annually updated and signed the facility's written manual, which delineates the project policies and procedures.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director of Quality Assurance will create a document that allows the Project Director to sign off on the policy on an annual basis. This will be kept with the written Policy and Procedure. This sheet will be updated on a yearly basis to ensure compliance in the future.
Project Director will sign off on the manual by 10/18/2019.
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709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
The facility failed to ensure that personnel records contained documentation of an annual written individual performance evaluation in one of nine employee records reviewed.
Employee # 1 was hired as the project director on January 15, 2013. There was no documentation of an annual written individual performance evaluation completed for the current review year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All employees must have an annual written individual performance evaluation.
A member of the Governing Body will complete an individual performance evaluation on Employee #1 by 12/31/2019.
Moving forward the Director of Quality Assurance will complete quarterly audits of personnel records. If they evaluations are not completed the Director of Quality Assurance will instruct that individual's supervisor to complete the evaluation. |
709.28 (a) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(2) Identification of project staff having access to records, and the methods by which staff gain access.
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Observations
The facility failed to include, in their confidentiality written policy and procedure, the identification of project staff having access to records, and the methods by which the staff gain access.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director of Quality Assurance will update the written Confidentiality Policy and Procedure to include which project staff has access to records. The update to the policy will also include the method in which staff gains access.
Project Director will review this updated policy to ensure compliance. |
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
The facility failed to obtain an informed and voluntary consent to release information form prior to the disclosure of information in 1 of 14 client records reviewed.
Client # 13 was admitted to the outpatient level of care on January 30, 2019 and was discharged on March 4, 2019. There was documentation of three facsimiles sent to a government agency on February 14, 2019, February 27, 2019 and March 20, 2019; however, there was no consent to release information form to the government agency on file prior to any of the disclosures.
These findings were reviewed with facility staff during the licensing process
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Plan of Correction
Director of Quality Assurance and Executive Director will retrain Care Manager to the guidelines around consents to ensure that proper consents are in place before any information is sent. This will occur by 10/18/19.
Moving forward Director of Quality Assurance will audit client records and consents on a bi-weekly basis to ensure that no information is being released without a proper consent.
Client #13 is no longer a client here. |
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
The facility failed to include documentation verifying written acknowledgement by clients that they had been informed that 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 and that no client may be deprived of a civil right solely by reason of treatment in 1 of 14 client records reviewed.
Client # 13 was admitted to the outpatient level of care on January 30, 2019 and was discharged on March 4, 2019.
These findings were reviewed with facility staff during the licensing process
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Plan of Correction
Care Manager will ensure that clients at all levels of care will sign a documentation reviewing client rights upon admission to the program. Once a client is admitted into the program Care Manager will review the documentation to verify all proper documentation is signed.
Director of Quality Assurance will audit all admission paperwork on a bi-weekly basis.
Client #13 is no longer a client here. |
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.
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Observations
The facility failed to include documentation verifying written acknowledgement by clients that they had been informed that 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, in 1 of 14 client records reviewed.
Client # 13 was admitted to the outpatient level of care on January 30, 2019 and was discharged on March 4, 2019.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Care Manager will ensure that clients at all levels of care will sign a documentation reviewing client rights upon admission to the program. Once a client is admitted into the program Care Manager will review the documentation to verify all proper documentation is signed.
Director of Quality Assurance will audit all admission paperwork on a bi-weekly basis.
Client #13 is no longer a client here.
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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
The facility failed to include documentation verifying written acknowledgement by clients that they had been informed 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 and that the reasons for removing sections shall be documented in the record, in 1 of 14 client records reviewed.
Client # 13 was admitted to the outpatient level of care on January 30, 2019 and was discharged on March 4, 2019.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Care Manager will ensure that clients at all levels of care will sign a documentation reviewing client rights upon admission to the program. Once a client is admitted into the program Care Manager will review the documentation to verify all proper documentation is signed.
Director of Quality Assurance will audit all admission paperwork on a bi-weekly basis.
Client #13 is no longer a client here.
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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
The facility failed to include documentation verifying written acknowledgement by clients that they had been informed that clients have the right to appeal a decision limiting access to their records to the director, in 1 of 14 client records reviewed.
Client # 13 was admitted to the outpatient level of care on January 30, 2019 and was discharged on March 4, 2019.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Care Manager will ensure that clients at all levels of care will sign a documentation reviewing client rights upon admission to the program. Once a client is admitted into the program Care Manager will review the documentation to verify all proper documentation is signed.
Director of Quality Assurance will audit all admission paperwork on a bi-weekly basis.
Client #13 is no longer a client here.
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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
The facility failed to include documentation verifying written acknowledgement by clients that they had been informed that clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records in 1 of 14 client records reviewed.
Client # 13 was admitted to the outpatient level of care on January 30, 2019 and was discharged on March 4, 2019.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Care Manager will ensure that clients at all levels of care will sign a documentation reviewing client rights upon admission to the program. Once a client is admitted into the program Care Manager will review the documentation to verify all proper documentation is signed.
Director of Quality Assurance will audit all admission paperwork on a bi-weekly basis.
Client #13 is no longer a client here.
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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
The facility failed to include documentation verifying written acknowledgement by clients that they had been informed that clients have the right to submit rebuttal data or memoranda to their own records.
Client # 13 was admitted to the outpatient level of care on January 30, 2019 and was discharged on March 4, 2019.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Care Manager will ensure that clients at all levels of care will sign a documentation reviewing client rights upon admission to the program. Once a client is admitted into the program Care Manager will review the documentation to verify all proper documentation is signed.
Director of Quality Assurance will audit all admission paperwork on a bi-weekly basis.
Client #13 is no longer a client here.
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