INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 26, 2024 through August 28, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Summit BHC Westfield, LLC d/b/a Mountain Laurel Recovery Center 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of fourteen personnel records, the facility failed to ensure that two counselor assistants were counseling clients under the supervision of a trained counselor or clinical supervisor based on their education.
Employee # 13 was hired as a counselor assistant on March 19, 2024. Employee # 13 had a high school diploma at the time of hire and may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor. Employee # 13 did not receive documented direct supervision from March 19, 2024 - June 19, 2024 or documented close supervision from June 19, 2024 through the date of inspection.
Employee # 14 was hired as a counselor assistant on June 18, 2024. Employee # 14 had a high school diploma at the time of hire and may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor. Employee # 14 did not receive documented direct supervision from June 18, 2024 through the date of inspection.
Direct observation is defined by regulation as follows: "In person observation of staff working in a clinical setting for the purpose of planning, oversight, monitoring and evaluating their activities." In accordance with 28 Pa. Code 704.9(a), a counselor assistant must be supervised by a fulltime clinical supervisor or a full-time counselor. The fully qualified clinical supervisor or counselor is then responsible for weekly supervision notes relating to the counselor assistant. Clear documentation in the weekly notes and in the pertinent client charts must also demonstrate that direct observation is occurring.
Close supervision is defined by regulation as follows: "Formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week."
Documented supervision did not identify that direct observation or formal case reviews were occurring in the dates noted above.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Clinical Services will be retrained on the documentation requirements of counselor assistant supervision by the Director of Quality Improvement. This training will occur on 9/27/2024. The Director of Clinical Services will document supervision appropriately. This will be audited by the Director of Human Resources, or designee, with a target goal of 100% compliance and reported quarterly to the Committee of the Whole. This audit will continue to occur as long as there is counselor assistants employed by Mountain Laurel Recovery Center. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of fourteen personnel records, the facility failed to ensure that two employees had an initial written individual training plan that was developed within 30 days from the date of hire.
Employee # 9 was hired as a counselor on June 18, 2024 and was current in that position at the time of the inspection. Employee # 9 should have had an initial individual training plan developed within 30 days of the date of hire, however a written individual training plan was not developed until August 13, 2024.
Employee # 14 was hired as a counselor on June 18, 2024 and was current in that position at the time of the inspection. Employee # 14 should have had an initial individual training plan developed within 30 days of the date of hire, however a written individual training plan was not developed until August 13, 2024.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Human Resources, or designee, will audit with a target goal of 100% compliance, new hire files during the fourth week of employment to ensure department heads complete training plans within the designated timeframe. This audit will occur for all new hire files moving forward. The Director of Human Resources will review any findings with the appropriate department to head to ensure creation of a training plan within the appropriate timeframe. Any findings will be reported during the daily Leadership Flash Meeting. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of fourteen personnel records, the facility failed to ensure that each counselor completed at least 25 clock hours of training annually during the facility's January 1, 2023 through December 31, 2023 training year in one of one applicable personnel record reviewed.
Employee # 6 has been in the position of counselor since January 30, 2022. The personnel record documented only 7 hours of annual training during the training year reviewed.
This is a repeat citation from the October 12, 2023 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Human Resources Director, or designee, will verify through an audit of clinical staff files for 100% compliance that training has occurred in accordance with regulation 704.11(f) quarterly. Any files that are noncompliant will be addressed with the Director of Clinical Services to verify a plan to complete the appropriate amount of training hours is in place. The Human Resources Director will report their findings to the Committee of the Whole bi-annually. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection on August 28, 2024, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. In the Residential Building, a group in the Community Room could be seen through the glass door and hallway windows at 10:05 a.m. A group in room 410 could be seen through the windows on the group room doors at 10:17 a.m. In the Dorms, a group in the lounge could be seen outside of the group room through the windows on the hallway doors and exterior windows at 10:39 a.m.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Mountain Laurel Recovery Center purchased blinds for all of the aforementioned areas. The blinds have been installed making the counseling areas compliant with regulation 705.4 (3). The Director of Facility Operations will check the condition of the blinds monthly during their monthly facility walkthrough. The results of the walkthroughs will be reported quarterly to the Committee of the Whole. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of fourteen personnel records, the facility failed to ensure that each staff was instructed in the use of the fire extinguishers upon employment in one record reviewed.
Employee # 11 was hired as a counselor on February 12, 2024 and was due to be trained in the use of fire extinguishers upon employment; however, fire safety training was not documented as complete until April 30, 2024.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Human Resources, or designee, will schedule all new hires to complete their fire safety training with the Safety Officer prior to the end of their first seven days of employment. The Director of Human Resources, or designee, will audit new hire files with a target goal of 100% compliance during the first week of employment to ensure the training has occurred and been documented appropriately. This audit will occur for all new hire files moving forward. Any findings will be reported during the daily Leadership Flash Meeting. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill logs from October 2023 through July 2024, the facility failed to conduct an unannounced fire drill during December 2023.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Quality Improvement will coordinate with the Safety Officer to ensure fire drills are scheduled appropriately. The Director of Quality Improvement, or designee, will audit with a goal of 100% compliance the fire drill log once a quarter to ensure compliance has occurred according to regulation 705.10 (d)(1). Findings will be reported to the Committee of the Whole Quarterly. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of fourteen personnel records, the facility failed to ensure that one applicable staff member was trained to perform assigned tasks during emergencies prior to being on shift.
Employee # 11 was hired as a counselor on February 12, 2024 and is current in that position. Employee # 11 began working shifts on February 12, 2024, but was not trained to perform assigned tasks during emergencies until April 30, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Human Resources, or designee, will schedule all new hires to complete their emergency preparedness training with the Safety Officer prior to the end of their first seven days of employment. The Director of Human Resources, or designee, will audit new hire files with a goal of 100% compliance during their first week of employment to ensure the training has occurred and been documented appropriately. This audit will occur for all new hire files moving forward. Any findings will be reported during the daily Leadership Flash Meeting. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of fire drill logs from October 2023 through July 2024 and the daily programming schedules presented by facility staff, the facility failed to conduct fire drills during sleeping hours at least every six months. The facility ' s sleeping hours are from 10:00 p.m. to 6:30 a.m. The only fire drills conducted during sleeping hours were in April and May 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Quality Improvement will coordinate with the Safety Officer to ensure fire drills are scheduled appropriately. The Director of Quality Improvement, or designee, will audit the fire drill log once a quarter with a goal of 100% compliance, to ensure compliance has occurred according to regulation 705.10 (d)(1). Findings will be reported to the Committee of the Whole Quarterly. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients in two of four applicable records reviewed.
Client # 6 was admitted to the Detoxification level of care on July 11, 2024 and was discharged Against Staff Advice (ASA) on July 17, 2024. The facility failed to follow their policy related to ASA discharges of calling the Emergency Contact within twelve hours.
Client # 15 was admitted to the Detoxification level of care on June 21, 2024 and was discharged Against Staff Advice (ASA) on June 26, 2024. The facility failed to follow their policy related to ASA discharges of calling the Emergency Contact within twelve hours.
This is a repeat citation from the October 12, 2023 and October 5, 2022 annual licensing renewal inspections.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
The Director of Quality Improvement, or designee, will audit the files of any AMA's weekly to ensure the emergency contact call occurred per policy, with a target goal of 100% compliance. This audit will occur until 6 continuous months of 100% compliance has been achieved. Any findings will be reviewed directly with the Director of Clinical Services and noncompliant staff will be given remedial training. Findings will be reported to the Committee of the Whole Quarterly. |
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 fourteen client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in five records reviewed.
Client # 1 was admitted to the detoxification level of care on February 24, 2024 and transferred to a lower level of care on March 1, 2024. The record contained documentation of billing throughout the treatment episode; however, the informed and voluntary consent to release information form to the funding source expired on February 23, 2024.
Client # 6 was admitted to the detoxification level of care on July 11, 2024 and was discharged on July 17, 2024. The record did not contain an informed and voluntary consent form to the funding source; however, there was evidence of billing.
Client # 8 was transferred to the rehabilitation level of care from a higher level of care on March 1, 2024 and discharged on April 10, 2024. The record contained documentation of communication with a family member on March 2, 2024, March 12, 2024, March 19, 2024, and April 10, 2024; however, the informed and voluntary consent to release information form to the family member expired on February 23, 2024.
Client # 10 was transferred to the rehabilitation level of care from a higher level of care on November 27, 2023 and was discharged on December 4, 2023. The record contained documentation of a notification of termination letter provided to the client on December 4, 2023, that contained the full name and date of termination of another client at the facility.
Client # 14 was admitted to the rehabilitation level of care on July 31, 2023 and was active at the time of the inspection. The record did not contain an informed and voluntary consent form to the funding source; however, there was evidence of billing.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff responsible for completion of ROI's will be retrained on how to appropriately fill out an ROI. Charts will be audited daily by the Director of Admissions, or designee, to ensure ROI's were completed appropriately, with a target goal of 100% compliance. This audit will occur until 6 continuous months of 100% compliance has been achieved. The Director of Admissions will report any findings daily in the leadership flash meeting to ensure corrections occur in a timely manner. Client # 14 was discharged from the program prior to completion of the corrective action. |
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.
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Observations
Based on a review of fourteen client records, the facility failed to ensure that informed and voluntary consent to release information forms included the specific information to be disclosed in two records reviewed.
Client # 7 was admitted to the detoxification level of care on July 19, 2024 and was discharged on July 27, 2024. The record contained a consent to release information form to a treatment provider signed by the client on July 21, 2024, that was missing the specific information to be disclosed.
Client # 8 was transferred to the rehabilitation level of care from a higher level of care on March 1, 2024 and discharged on April 10, 2024. The record contained a consent to release information form to a treatment provider signed by the client on March 8, 2024, that was missing the specific information to be disclosed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff responsible for completion of ROI's will be retrained on how to appropriately fill out an ROI. Charts will be audited daily by the Director of Admissions, or designee, to ensure ROI's were completed appropriately, with a target goal of 100% compliance. This audit will occur until 6 continuous months of 100% compliance has been achieved. The Director of Admissions will report any findings daily in the leadership flash meeting to ensure corrections occur in a timely manner. |
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 a review of fourteen client records, the facility failed to ensure that consent to release information forms included the dated signature of the client in four records reviewed.
Client # 4 was admitted to the detoxification level of care on April 29, 2024 and was transferred to a lower level of care on May 6, 2024. The record contained a consent to release information form to the funding source that was signed by the client, however, the signature did not include a date.
Client # 5 was admitted to the detoxification level of care on June 13, 2024 and was discharged on June 17, 2024. The record contained a consent to release information form to the funding source that was signed by the client, however, the signature did not include a date.
Client # 12 was admitted to the rehabilitation level of care on August 8, 2024 and was active at the time of the inspection. The record contained a consent to release information form to the funding source that was signed by the client, however, the signature did not include a date.
Client # 13 was transferred to the rehabilitation level of care from a higher level of care on August 5, 2024 and was active at the time of the inspection. The record contained a consent to release information form to the funding source that was signed by the client, however, the signature did not include a date.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff responsible for completion of ROI's will be retrained on how to appropriately fill out an ROI. Charts will be audited daily by the Director of Admissions, or designee, with a target goal of 100% compliance. This audit will occur until 6 continuous months of 100% compliance has been achieved. The Director of Admissions will report any findings daily in the leadership flash meeting to ensure corrections occur in a timely manner. Client #12 and #13 were active at the time of the inspection, they were discharged from the program prior to completion of the corrective action. |
709.63(a)(6) LICENSURE Aftercare plan
709.63. 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:
(6) Aftercare plans, if applicable.
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Observations
Based on a review of client records and the facility ' s policy and procedure manual, the facility failed to ensure a complete client record on an individual which includes information relative to the client's involvement with the project, including an aftercare plan provided to the client, in one of one applicable record reviewed.
Client # 7 was admitted to the Detoxification level of care on July 19, 2024 and was discharged on July 27, 2024. The record did not contain documentation that the client received a copy of the aftercare plan.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical department will be retrained on regulation 709.63(a)(6) pertaining to a client receiving a copy of their aftercare plan. This will be audited weekly by the Director of Clinical Services, or designee, with a target goal of 100% compliance. This audit will occur until 6 continuous months of 100% compliance has been achieved. Findings will be reported to the Committee of the Whole Quarterly. |
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.
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Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in six of seven records reviewed.
Client # 8 was transferred to the rehabilitation level of care from a higher level of care on March 1, 2024 and discharged on April 10, 2024. The individual treatment and rehabilitation plan was completed on February 28, 2024; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
Client # 9 was transferred to the rehabilitation level of care from a higher level of care on January 8, 2024 and discharged on January 24, 2024. The individual treatment and rehabilitation plan was completed on January 12, 2024; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
Client # 10 was transferred to the rehabilitation level of care from a higher level of care on November 27, 2023 and was discharged on December 4, 2023. The individual treatment and rehabilitation plan was completed on November 27, 2023; however, the plan did not include documentation of the frequency of treatment and rehabilitation services.
Client # 11 was transferred to the rehabilitation level of care from a higher level of care on May 6, 2024 and was discharged on June 11, 2024. The individual treatment and rehabilitation plan was completed on May 11, 2024; however, the plan did not include documentation of the frequency of treatment and rehabilitation services.
Client # 12 was admitted to the rehabilitation level of care on August 8, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on August 13, 2024; however, the plan did not include documentation of the frequency of treatment and rehabilitation services.
Client # 13 was transferred to the rehabilitation level of care from a higher level of care on August 5, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on August 13, 2024; however, the plan did not include documentation of the frequency of treatment and rehabilitation services.
These finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical department will be retrained on regulation 709.52(a)(2) pertaining to a treatment plan including the type and frequency of rehabilitation services. This training will occur on 9/25/2024. This will be audited weekly by the Director of Clinical Services, or designee, with a target goal of 100% compliance. This audit will occur until 6 continuous months of 100% compliance has been achieved. Findings will be reported to the Committee of the Whole Quarterly. |
709.53(a)(5) LICENSURE Progress Notes
709.53. 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:
(5) Progress notes.
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Observations
Based on a review of client records and the facility policies and procedures, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include individual progress notes documented within 24 hours of each session, per a discussion with the Facility Director, in three of seven records reviewed.
Client # 8 was transferred to the rehabilitation level of care from a higher level of care on March 1, 2024 and discharged on April 10, 2024. The record contained a progress note for an individual session occurring on April 1, 2024, that was not completed until April 5, 2024. Additionally, the record contained documentation of an individual session occurring on April 8, 2024, that was not completed as of the date of the inspection.
Client # 14 was admitted to the rehabilitation level of care on July 31, 2024 and was active at the time of the inspection. The record contained progress notes for individual sessions occurring on August 7, 2024 and August 14, 2024, that were not completed until August 23, 2024.
Client # 19 was admitted to the rehabilitation level of care on July 31, 2024 and was active at the time of the inspection. The record contained a progress note for an individual session occurring on August 13, 2024, that was not completed until August 25, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical department will be retrained on the regulation 709.53(a)(5) pertaining to individual session notes being entered into the record within 24 hours as well as necessary signatures being completed. This training will occur on 10/2/2024. This will be audited weekly by the Director of Clinical Services, or designee, with a target goal of 100% compliance. This audit will occur until 6 continuous months of 100% compliance has been achieved. Findings will be reported to the Committee of the Whole Quarterly. |
709.53(a)(8) LICENSURE Case Consultation Notes
709.53. 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:
(8) Case consultation notes.
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Observations
Based on a review of client records and the facility policy and procedures, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include case consultation information within 21 days of admission, per a discussion with the Facility Director, in three of four applicable records reviewed.
Client # 8 was transferred to the rehabilitation level of care from a higher level of care on March 1, 2024 and discharged on April 10, 2024. There was no documentation of case consultation information in the record.
Client # 14 was admitted to the rehabilitation level of care on July 31, 2024 and was active at the time of the inspection. There was no documentation of case consultation information in the record.
Client # 19 was admitted to the rehabilitation level of care on July 31, 2024 and was active at the time of the inspection. There was no documentation of case consultation information in the record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical department will be retrained on the regulation 709.53(a)(8) pertaining to case consultation notes and having them entered in a timely manner as well as filled fully and appropriately. This training will occur on 10/2/2024. This will be audited weekly by the Director of Clinical Services, or designee, with a target goal of 100% compliance. This audit will occur until 6 continuous months of 100% compliance has been achieved. Findings will be reported to the Committee of the Whole Quarterly. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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 a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include follow-up information within seven days of discharge, per facility policy, in two of three applicable records reviewed.
Client # 8 was transferred to the rehabilitation level of care from a higher level of care on March 1, 2024 and discharged on April 10, 2024. Follow-up information was not completed until May 10, 2024.
Client # 11 was transferred to the rehabilitation level of care from a higher level of care on May 6, 2024 and was discharged on June 11, 2024. Follow-up information was not completed until August 15, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Alumni Coordinator will be retrained on the follow-up call policy. This training will occur on 9/23/24. The Alumni Coordinator will keep a follow up call log to ensure the policy is followed. The log will be audited Quarterly, with a target goal of 100% compliance, by the Director of Business Development, or designee. This audit will occur until 6 continuous months of 100% compliance has been achieved. Findings will be reported to the CEO and Director of Quality Improvement quarterly for review. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for calling client emergency contacts within 12 hours of an Against Staff Advice discharge was submitted and approved by the Department for the October 12, 2023 and October 5, 2022 annual licensing inspections. Contacting emergency contacts was again found to be a deficiency in the August 26, 2024 through August 28, 2024 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO will review progress of all listed corrective actions to ensure they are being followed and completed appropriately. This will be accomplished through close collaboration with the Director of Quality Improvement who is responsible for implementation, tracking, audits, and oversight. Review of progress of stated corrective actions will be addressed monthly by the CEO and the Director of Quality Improvement with the appropriate department heads. |