INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 27, 2023 through April 28, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Recovery Cove 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:
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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 document that a copy of a client consent was offered to the client for each release of information form in thirteen of thirteen client records reviewed.
In each client record reviewed, there were release of information forms titled "Blank" that the facility completed. Each "Blank" release of information form in every client record reviewed and there was no other documentation in the record that indicated a copy of each client consent was offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.28(d)- On May 3rd 2023, Program Director added to the clients chart, A copy of a client consent shall be offered to the client and a copy maintained in client record, to Release of information "Blank." Random chart audits were performed by Program director , on clients charts to ensure the revised consent form was updated . |
709.30 (2) 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.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right that the project may not discriminate in the provision of services on the basis of ethnicity, color, marital status, sexual orientation or handicap in thirteen of thirteen applicable client records reviewed.
In all thirteen client records reviewed, the client rights acknowledgement form did not include notification of this regulatory client right and there was no other documentation indicating the client was notified of the client right.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.30 (2)- On May 8th 2023 Program Director added to Client Rights acknowledgment about notifying the client of the client rights. Random chart audits were performed by the Program Director to ensure the revised acknowledgement form was added to the client rights. |
709.30 (3) 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.
(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.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified that 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 and that reasons for removing sections shall be documented in the record in thirteen of thirteen applicable client records reviewed.
In all thirteen client records reviewed, the client rights acknowledgement form did not include notification of this regulatory client right and there was no other documentation indicating the client was notified of the client right.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.30(3)- On May 8th 2023, Program Director added to Client Rights in EMR, that 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. (See #21) . Random chart audits were performed by Program Director to ensure the clients rights to inspect was added to client rights. |
709.30 (4) 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.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right to appeal a decision limiting access to their records to the director in thirteen of thirteen applicable client records reviewed.
In all thirteen client records reviewed, the client rights acknowledgement form did not include notification of this regulatory client right and there was no other documentation indicating the client was notified of the client right.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.30(4)- On May 8th, 2023, Program Director added to Client Rights in EMR, Clients have the right to appeal a decision limited access to their records to the director. (See #21a) . Random chart audits were performed by Program Director, to ensure the clients have the right to appeal , was added to client rights. |
709.30 (5) 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.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right to request the correction of inaccurate, irrelevant, outdated, or incomplete information in their records in thirteen of thirteen applicable client records reviewed.
In all thirteen client records reviewed, the client rights acknowledgement form did not include notification of this regulatory client right and there was no other documentation indicating the client was notified of the client right.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.30 (5)- On May 8th, 2023, Program Director added to Client Rights in EMR, Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records (See #21b) Client rights were updated in the client handbook. Random chart audits were performed by Program director, to ensure the right to request correction of inaccurate was added to the client rights. |
709.30 (6) 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.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right to submit rebuttal data or memoranda to their own records in their records in thirteen of thirteen applicable client records reviewed.
In all thirteen client records reviewed, the client rights acknowledgement form did not include notification of this regulatory client right and there was no other documentation indicating the client was notified of the client right.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.30 (6)- On May 8th, 2023, Program Director, added to Client Rights in EMR, Clients have the right to submit rebuttal data or memoranda to their own records (See #21c). Random chart audits were performed by Program Director to ensure the right to submit rebuttal data was added to the client rights. |
709.82(a)(2) LICENSURE Treatment and rehabilitation services
709.82. 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 client's treatment and rehabilitation plan in three of six applicable partial hospitalization client records reviewed.
Client # 1 was admitted to the partial hospitalization activity on April 6, 2023 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on April 10, 2023; however, the plan did not include the frequency of treatment and rehabilitation services.
Client # 2 was admitted to the partial hospitalization activity on April 12, 2023 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on April 14, 2023; however, the plan did not include the frequency of treatment and rehabilitation services.
Client # 6 was admitted to the partial hospitalization activity on November 29, 2022 and was discharged on December 26, 2022. The individual treatment and rehabilitation plan was completed on December 2, 2022; however, the plan did not include the frequency of treatment and rehabilitation services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.82(a)(2)- On May 2nd, 2023, Program Director informed Clinical staff during group supervision meeting, that all treatment plans will need to reflect frequency of treatment and rehabilitation services with all PHP clients. Treatment plans will be reviewed and signed off by Clinical director. If the frequency of treatment and rehabilitation services are not present, clinical staff will meet with client to incorporate into treatment plan .
Client #1, frequency of treatment and rehabilitation services will be updated in next treatment plan review.
Client #2, Client #1, frequency of treatment and rehabilitation services will be updated in next treatment plan review.
Client #6, unable to update due to client discharge from program.
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709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of client records, the facility failed to assure that clients admitted to the partial hospitalization program received individual counseling services at least twice a week in six of six applicable client records.
In every partial hospitalization client record reviewed, the record of service and progress notes indicated that individual counseling sessions occurred once a week, rather than twice a week for the entire treatment episode of each client reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.82(d)(1)- On May 2nd, 2023, Program Director, informed Clinical staff during Group Supervision meeting, that PHP clients will meet with counselor twice a week for individual sessions starting May 3rd, 2023. Random chart audits were completed by Program Director on PHP clients to ensure staff is meeting with clients twice a week. |
709.83(a)(11) LICENSURE Client records
709.83. 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 maintain a complete client record, which is to include follow-up information, in one of three applicable client records reviewed.
Client # 5 was admitted to the partial hospitalization activity on October 18, 2022 and was discharged on November 7, 2022. There was no documentation of follow-up information in the record as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.83(a)(110, On May 5th, 2023, Program Director, implemented a 30 day follow up call procedure for all discharged clients. An excel spreadsheet was created with Discharge Date, Client name, 30-day call, and Comments. Random audits will be performed by Program director, to ensure follow up calls are being made to discharged clients, any comments will be reviewed with staff at monthly supervision or as needed, to address any improvements |
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
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual client's treatment and rehabilitation plan in three of six applicable outpatient client records reviewed.
Client # 8 was admitted to the outpatient activity on January 23, 2023 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on January 23, 2023; however, the plan did not include the frequency of treatment and rehabilitation services.
Client # 9 was admitted to the outpatient activity on February 2, 2023 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on February 15, 2023; however, the plan did not include the frequency of treatment and rehabilitation services.
Client # 12 was admitted to the outpatient activity on November 21, 2022 and was discharged on March 23, 2023. The individual treatment and rehabilitation plan was completed on December 15, 2022; however, the plan did not include the frequency of treatment and rehabilitation services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.92(a)(2) On May 2nd, 2023, Program Director, informed clinical staff during Group Supervision, all Treatment plans will need to have the frequency of treatment and rehabilitation services on the individual client's treatment plan, starting on May 3rd, 2023. Treatment plans will be reviewed and signed off by Clinical director. If the frequency of treatment and rehabilitation services are not present, clinical staff will meet with client to add into treatment plan.
Client #8, the frequency of treatment and rehabilitation services will be updated at the next treatment plan review by clinician.
Client #9, the frequency of treatment and rehabilitation services will be updated at next treatment plan review by clinician.
Client #12, unable to add frequency of treatment rehabilitation due to client discharging from program
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709.93(a)(11) LICENSURE Client records
709.93. 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 maintain a complete client record, which is to include follow-up information, in three of three applicable client records reviewed.
Client # 11 was admitted to the outpatient activity on October 12, 2022 and was discharged on February 28, 2023. There was no documentation of follow-up information, in the record, as of the date of the inspection.
Client # 12 was admitted to the outpatient activity on November 21, 2022 and was discharged on March 23, 2023. There was no documentation of follow-up information, in the record, as of the date of the inspection.
Client # 13 was admitted to the outpatient activity on October 15, 2022 and was discharged on December 25, 2022. There was no documentation of follow-up information, in the record, as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.93(a)(11) On May 5th, 2023,Program Director, implemented 30 day follow up call procedure for all discharged clients. An excel spreadsheet was created with Discharge Date, Client name, 30-day call, and Comments. Random audits will be performed by Program director, to ensure follow up calls are being made to discharged clients, any comments will be reviewed with staff at monthly supervision or as needed, to address any improvements |