INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 30, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, St. John Vianney 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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709.123(a)(2)(i) LICENSURE Disclosure of Criteria
709.123. Treatment and rehabilitation.
(a) Intake and admission.
(2) Intake procedures shall include documentation of:
(i) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on a review of client records, the facility failed to document disclosure to the client of criteria for admission, treatment completion and discharge in seven out of seven records reviewed.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
St. John Vianney Center currently provides a comprehensive Resident Orientation booklet upon admission which describes criteria for admission, treatment completion, and discharge. The Director of Regulatory Compliance will develop an Acknowledgement of Receipt form to serve as documentation that this information has been provided to the Resident.
All new admissions will be asked to complete the Resident Orientation Acknowledgement of Receipt form effective 6/24/2024.
All active program participants will be asked to complete the acknowledgment form by 6/28/2024.
The Director of Regulatory Compliance, or designee, will complete a chart review to confirm completion of the Acknowledgement of Receipt within 7 days of admission to the facility. Auditing will continue until 6 consecutive months of 100% compliance is achieved. |
709.123(b)(2) LICENSURE Tx Plan Update
709.123. Treatment and rehabilitation.
(b) Treatment and rehabilitation services.
(2) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regimen is less than 30 days, the treatment and rehabilitation plan review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in three out of seven records reviewed.Client #1 was admitted on December 22, 2023 and was still active at the time of the inspection. A treatment plan update was completed on February 23, 2024 and an update was due no later than March 24, 2024; however, it was not completed until March 27, 2024. Client #2 was admitted on March 13, 2024 and was still active at the time of the inspection. A treatment plan update was completed on April 25, 2024 and an update was due no later than May 25, 2024; however, none was completed.Client #7 was admitted on January 3, 2024 and was discharged on May 3, 2024. A treatment plan update was completed on January 11, 2024 and the next update was due no later than February 11, 2024; however, it was not completed until March 1, 2024.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Clinical Director will provide in-service training for all Primary Therapists to review treatment plan timeliness and discuss compliance challenges.
Our current Electronic Health Record system will be configured to generate an alert to Primary Therapists notifying them when a 30-Day Treatment Plan due date is approaching.
Timely 30-Day Treatment Plan completion will be monitored with monthly chart audits completed by the Manager of Quality for all program participants. Audit results will be reviewed monthly by the Clinical Director and members of the facility's Performance Improvement Committee for on-going compliance monitoring.
The Clinical Director will provide direct supervision to any staff unable to meet the required treatment plan expectations. |
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 client records, the facility failed to obtain a completed informed and voluntary consent which included the dated signature of client in one out of seven records reviewed.Client # 4 was admitted on March 22, 2024 and was still active at that the time of the inspection. One release of information dated May 28, 2024 was to a physician and an additional release of information dated May 28, 2024 was to a community member. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
St. John Vianney Center has amended its process of generating Release of Information forms within the Electronic Health Record. Effective 6/17/2024, no release form will be started prior to meeting with the resident. This will eliminate the occurrence of saving an incomplete release of information form in the medical record.
The Director of Regulatory Compliance will facilitate an in-service training with Medical Records Department staff to review the process change by 6/28/2024.
The Director of Regulatory Compliance, or designee, will complete a monthly medical record audit to include 10% of active, randomly selected program participants. Record creation date and signature date/time stamps will be compared to ensure releases are not initiated on a date prior to meeting with the resident. Auditing will continue until 6 consecutive months of 100% compliance is achieved. |