INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 27-28, 2018, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Blueprints for Addiction Recovery, Inc. 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) (5) 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:
(5) Dated signature of witness.
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Observations
The facility failed to obtain informed and voluntary consents from clients that included all of the required documentation before releasing information from client records in 1 of 16 client records reviewed during the on-site inspection. Client #10 was admitted for treatment on October 12, 2018, and discharged on October 30, 2018. There was a letter sent to the client's probation officer dated October 30, 2018, but the release of information for the client's probation department did not have a witness signature. These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
The client in question has been discharged from the facility. Clinical Director reviewed how to complete releases of information with clinical and other staff who complete releases during clinical meeting on 12/4/18. Clinical Director will review all releases completed by staff upon admission to ensure that all releases are fully completed beginning 12/4/18. |
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 acquire written acknowledgement from clients that the clients were informed of their rights in 1 of 2 intake, evaluation and referral activity records reviewed during the on-site inspection. There was no documentation that Client #16 was informed of the following 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. (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. (4) Clients have the right to appeal a decision limiting access to their records to the director. (5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records. (6) Clients have the right to submit rebuttal data or memoranda to their own records. These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
The facility will always acquire written acknowledgement from clients that the clients were informed of their rights through reading and signing Notice of Privacy Practices form. Clinical Director reviewed privacy practices notice with counselors on 12/4/18. Clinical Director will audit evaluation and referral activity records in order to ensure compliance with regulation beginning 12/4/18. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
The facility failed to document that it notified clients in writing of decisions to involuntarily terminate the clients' treatment at the project in 1 of 3 applicable records reviewed during the on-site inspection. Client #4 was admitted for treatment on September 25, 2018, and involuntarily discharged on October 11, 2018. These findings were reviewed with facility staff as aprt of the inspection process.
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Plan of Correction
The facility will begin providing notification of involuntary termination to all clients who have been involuntarily terminated from treatment. Clinical Director informed staff that they should always provide an involuntarily discharged client with notification that includes why they are being discharged, information on the appeals process, and a time frame for which the fair hearing should be had. This will begin on 12/11/18 and the Clinical Director will ensure that this is being done through audit of discharged client records. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
The facility failed to ensure that individualized treatment and rehabilitation plans documented the frequency and type of rehabilitation services in 3 of 7 outpatient client records reviewed during the on-site inspection. Client #8 was admitted for treatment on October 3, 2018, and discharged on October 16, 2018. The client's individualized treatment plan was dated October 3, 2018, but the treatment plan did not document the frequency of counseling. Client #12 was admitted for treatment on August 20, 2018, and was an active client at the time of the on-site inspection. The client's individualized treatment plan was dated October 3, 2018, and the client's treatment plan update was dated October 19, 2018, but the neither the treatment plan nor the treatment plan update documented the frequency of counseling. Client #14 was admitted for treatment on October 9, 2018, and was an active client at the time of the on-site inspection. The client's individualized treatment plan was dated October 9, 2018, but the treatment plan did not document the frequency of counseling. These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Type and frequency of therapy interventions will be added to the treatment plan in a more effective manner. Clinical Director informed staff of change and retrained staff on how to complete treatment plans in accordance with DDAP standards on 12/11/18. Clinical Director will review treatment plans to make sure they are up to standard and include type and frequency beginning 12/11/18. |
709.43(e) LICENSURE Consent to TX
709.43. Client management.
(e) A consent to treatment form should be completed and signed by the client and intake worker at intake.
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Observations
The facility failed to document a signed and completed consent to treatment form in 1 of 2 intake, evaluation and referral records reviewed during the on-site inspection. There was no signed consent to treatment form for client #16. These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Counselors will always review the elements of the consent to treat form with client and have the client sign consent to treat form. Clinical Director reviewed consent to treat form with counselors on 12/4/18. Clinical Director will audit evaluation and referral activity records in order to ensure compliance with regulation beginning 12/4/18. |