INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 5, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Passages to 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 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to ensure copies of all consent to release information forms were offered to the client in three of seven records.
Client #4 was admitted to the outpatient level of care on November 11, 2022 and was discharged December 21, 2022. The client record contained a consent form to a judge, signed by the client on November 11, 2022. There was no documentation in the record that the client was offered a copy of the consent form.
Client #5 was admitted to the outpatient level of care on September 21, 2022 and was discharged January 31, 2023. The client record contained a consent form to a judge, signed by the client on September 21, 2022. There was no documentation in the record that the client was offered a copy of the consent form.
Client #7 was admitted to the outpatient level of care on November 17, 2022 and was discharged April 12, 2023. The client record contained a consent form to a judge, signed by the client on November 17, 2022. There was no documentation in the record that the client was offered a copy of the consent form.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Passages Outpatient maintains electronic copies of Releases of Information in its electronic health record. The electronic health record (ClinicTracker) has been updated. ROI's and intake forms have been updated to a checkbox for "accepted" or "refused" a copy beneath the staff signature. The staff completed the release will ensure the client is signing off on the accepting on the acceptance or rejection of a copy. The Clinical Supervisor will regularly review all ROI's to ensure each participant is being offered a copy of the release of information.
Discharged clients have been mailed copies of the consents for there records. |
709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) 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 provide documentation of disclosure to the client of criteria for admission, treatment, completion and discharge in seven of seven client records.
These findings were reviewed with facility staff during the licensing process
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Plan of Correction
Passages to Recovery Clinical Supervisor and Director of Treatment created a document to review the program guidelines as outlined by licensing. Receipts will be signed by the client after review of the document and kept on file. The Clinical Supervisor will ensure the document is signed and filed during regular chart reviews. All active and future clients to sign and complete as of 7/20/2023.
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709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
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Observations
Based on a review of client records, the facility failed to provide documentation of client orientation to the project which shall include project policies in seven of seven client records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Passages to Recovery Clinical Supervisor and Dir. Of Treatment have developed orientation documents for the Outpatient Dept. that will specifically outline the policy of expectations of the project policies in seven of seven client records that were reviewed on site, and include an update for all current clients and will be reviewed with newly admitted clients at orientation. Receipts will be signed by the after review of the handbook. Date of completion 7/20/2023. Clinical Supervisor will be responsible to ensure intake staff are providing documentation to clients and receiving the signature page. |
709.91(b)(2)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(ii) Hours of operation.
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Observations
Based on a review of client records, the facility failed to provide documentation of client orientation to the project which shall include hours of operation in seven of seven client records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Passages to Recovery staff will begin to implement an orientation group that will provide the hours of operation for outpatient programs for all clients once admitted to 2.5,2.1,1.0 level of care.
The Clinical Supervisor will ensure attendance and completion of the group through regular record reviews and sign in sheets. All active and future clients will participate by 7/20/2023. |
709.91(b)(2)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iii) Fee schedule.
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Observations
Based on a review of client records, the facility failed to provide documentation of client orientation to the project which shall include fee schedule in seven of seven client records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Passages to Recovery Clinical Supervisor and Director of Treatment have developed an orientation document to specifically identify the fee scheduling. The Clinical Supervisor will review receipt during regular file reviews. All active and future clients will have required signature by 7/20/2023.
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709.91(b)(2)(iv) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iv) Services provided.
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Observations
Based on a review of client records, the facility failed to provide documentation of client orientation to the project which shall include services provided in seven of seven client records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All services provided will be outlined in the Passages to Recovery Outpatient Treatment Program Orientation document and presented during the Continuum of Care Orientation Group facilitated by PTR staff. The Clinical Supervisor will ensure completion through regular record review. The receipt and acknowledgement will be verified via signature of the review of the Outpatient charting. All active and future clients will have required signature by 7/20/2023. |