INITIAL COMMENTS
|
Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on April 21, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, Little Creek Lodge, 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
|
709.28 (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.
|
Observations
Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in four of seven client records reviewed.
Client #1 was admitted on January 29, 2021 and was a current client at the time of the inspection. A release of information form for the funding source was signed and dated on April 15, 2021; however, there is documentation in the client record of staff communicating with the funding source on April 8, 2021.
Client #3 was admitted on March 12, 2021 and was a current client at the time of the inspection. A release of information form for the funding source was signed and dated on April 15, 2021; however, there is documentation in the client record of staff communicating with the funding source on March 9, 2021, April 7, 2021 and April 13, 2021.
Client #5 was admitted on May 20, 2020 and was discharged on July 20, 2020. A release of information form for the funding source was signed and dated on July 20, 2021; however, there is documentation in the client record of staff communicating with the funding source on May 20, 2020, May 21, 2020, May 27, 2020, June 4, 2020 and June 19, 2020.
Client #7 was admitted on September 1, 2020 and was discharged on October 23, 2020. A release of information form for the funding source was not documented in the client records.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Clinical Director conducted an in-person Clinical Team meeting on 5/6/21. The program's confidentiality policy and associated commonwealth law 4 Pa Code 255.5 what distributed to each member and reviewed. Laws around release of information to funding sources and legal entities were discussed. Additionally, a blank 255.5 ROI was added to the client admission packet on 5/5/21. This was showed to the clinical team members in the meeting on 5/6/21 and they will now be completed with the client immediately upon admission with the other admission paperwork. These ROI's only contain the 5 items permitted to be released to these entities with the client's signed consent. Clinical Director will audit all completed admission paperwork for clients for the next 4 months, or until these forms are being properly completed 100% of the time over a 2 week period. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
|
Observations
Based on a review of client records, the project failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in five of seven client records reviewed.
Client #1 was admitted on January 29, 2021 and was a current client at the time of the inspection. A release of information form to a probation agency, signed and dated by the client on January 29, 2021, allowed for the release of treatment plan, BPS assessment, medical history/current status, discharge/transfer planning, discharge summary/aftercare recommendations, medical progress notes and assessments, urine analysis results, lab tests results, psychiatric history and assessment evaluations, family information, legal status and employment information, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #2 was admitted on March 8, 2021 and was a current client at the time of the inspection. A release of information form to a probation agency, signed and dated by the client on March 8, 2021, allowed for the release of treatment plan, BPS assessment, medical history/current status, discharge/transfer planning, discharge summary/aftercare recommendations, medical progress notes and assessments, urine analysis results, lab tests results, psychiatric history and assessment evaluations, family information, legal status and employment information, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #3 was admitted on March 12, 2021 and was a current client at the time of the inspection. A release of information form to a probation agency, signed and dated by the client on March 15, 2021, allowed for the release of treatment plan, BPS assessment, medical history/current status, discharge/transfer planning, discharge summary/aftercare recommendations, medical progress notes and assessments, urine analysis results, lab tests results, psychiatric history and assessment evaluations, family information, legal status and employment information, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #5 was admitted on May 20, 2020 and was discharged on July 20, 2020. A release of information form to court officials, signed and dated by the client on May 20, 2020, allowed for the release of treatment plan, BPS assessment, medical history/current status, discharge/transfer planning, discharge summary/aftercare recommendations, medical progress notes and assessments, urine analysis results, lab tests results, psychiatric history and assessment evaluations, family information, legal status and employment information, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #7 was admitted on September 1, 2020 and was discharged on October 23, 2020. A release of information form to a probation agency, signed and dated by the client on September 15, 2020, allowed for the release of treatment plan, BPS assessment, medical history/current status, discharge/transfer planning, discharge summary/aftercare recommendations, medical progress notes and assessments, urine analysis results, lab tests results, psychiatric history and assessment evaluations, family information, legal status and employment information, all of which exceeds the limits established by 4 Pa. Code 255.5.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Clinical Director conducted an in-person Clinical Team meeting on 5/6/21. The program's confidentiality policy and associated commonwealth law 4 Pa Code 255.5 what distributed to each member and reviewed. Laws around release of information to legal entities were discussed. Additionally, a blank 255.5 ROI was added to the client admission packet on 5/5/21. This was showed to the clinical team members in the meeting on 5/6/21 and they will now be completed with the client immediately upon admission with the other admission paperwork. These ROI's only contain the 5 items permitted to be released to these entities with the client's signed consent. Clinical Director will audit all completed admission paperwork for clients for the next 4 months, or until these forms are being properly completed 100% of the time over a 2 week period.
|
709.52(a)(2) LICENSURE Tx type & frequency
709.52. 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:
(2) Type and frequency of treatment and rehabilitation services.
|
Observations
Based on the review of client records, the project failed to document individual treatment and rehabilitation plans that included the type and frequency of treatment and rehabilitation services in six of seven client records reviewed.
Client #1 was admitted on January 29, 2021 and was a current client at the time of the inspection. A comprehensive treatment plan completed on February 3, 2021 did not document the type and frequency of treatment and rehabilitation services to be provided.
Client #2 was admitted on March 8, 2021 and was a current client at the time of the inspection. A comprehensive treatment plan completed on March 9, 2021 did not document the type and frequency of treatment and rehabilitation services to be provided.
Client #3 was admitted on March 12, 2021 and was a current client at the time of the inspection. A comprehensive treatment plan completed on March 15, 2021 did not document the type and frequency of treatment and rehabilitation services to be provided.
Client #5 was admitted on May 20, 2020 and was discharged on July 20, 2020. A comprehensive treatment plan completed on May 20, 2020 did not document the type and frequency of treatment and rehabilitation services to be provided.
Client #6 was admitted on August 28, 2020 and was discharged on October 23, 2020. A comprehensive treatment plan completed on August 31, 2020 did not document the type and frequency of treatment and rehabilitation services to be provided.
Client #7 was admitted on September 1, 2020 and was discharged on October 23, 2020. A comprehensive treatment plan completed on September 4, 2020 did not document the type and frequency of treatment and rehabilitation services to be provided.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
In a Clinical Team meeting on 5/6/21, the project's Policies and Procedures around Treatment and Rehabilitation Management were distributed and reviewed. The role of services offered as part the treatment planning process were reviewed. Additionally, the rationale behind documenting the type and frequency of such services was provided. Clinical Director will audit all client treatment planning records to ensure type and frequency of services are included for the next 4 months, or until these elements of the plan are being completed 100% of the time over a 2 week period.
|