INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up inspection conducted on May 6, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, A Better Today Inc. Satellite Hazleton 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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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, it was observed that the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside of the counseling room as a counselor was holding a counseling session with the door open.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A HIPAA compliance training has been scheduled for May 23, 2024, to re-educate all clinical staff on the importance of client confidentiality and privacy.
Clinical Supervisors will continue monitoring counselors to ensure they follow the proper steps to ensure HIPAA compliance.
Clinical Director will continue to stress the importance of being HIPAA compliant.
Responsible for these actions: Clinical Director, Clinical Supervisors, and Counselors
Time frame: Immediate action
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709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
The facility failed to ensure that all client records were kept within locked storage containers as the door to the file room was left opened and the file cabinets were left unlocked.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
A HIPAA compliance training has been scheduled for May 23, 2024, to re-educate all clinical staff on the importance of client confidentiality and privacy.
Clinical Supervisors will continue monitoring counselors to ensure they follow the proper steps to ensure HIPAA compliance.
Clinical Director will continue to stress the importance of being HIPAA compliant.
Responsible for these actions: Clinical Director, Clinical Supervisors, and Counselors
Time frame: Immediate action
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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 outpatient client records, the facility failed to obtain a consent to release information form prior to releasing information in four out of nine records reviewed. There was no consent to release information forms for the funding source. Facility staff confirmed billing had occurred.
Client #1 was admitted on November 1, 2023 and was still active at the time of the inspection.
Client #3 was admitted on February 6, 2024 and was still active at the time of the inspection.
Client #4 was admitted December 1, 2023 and was still active at the time of the inspection.
Client #5 was admitted on February 7, 2024 and was still active at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the October 23, 2023 licensing inspection.
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Plan of Correction
Client #1, #3, #4, and #5 have been scheduled for an individual session with their counselor to sign a new release to allow billing to the appropriate funding source. The billing release for client funding sources is part of the initial intake package and is usually completed with every client upon intake.
Clinical Supervisors have re-educated staff on the contents of the intake packet and staff was asked to monitor that all forms were completed accurately during intake. Moving forward, the Clinical Director will review charts after intake to ensure all releases were completed properly.
Responsible for these actions: Clinical Director, Clinical Supervisors, and Counselors
Time frame: Immediate action
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709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of outpatient client records, the facility failed to ensure that the individual treatment and rehabilitation plan included proposed type of support services in five out of five applicable records reviewed.
Client #2 was admitted on November 20, 2023 and was still active at the time of the inspection. A treatment plan was completed on November 22, 2023
Client #3 was admitted on February 6, 2024 and was still active at the time of the inspection. A treatment plan was completed on February 6, 2024
Client #4 was admitted December 1, 2023 and was still active at the time of the inspection. A treatment plan was completed on December 1, 2023
Client #5 was admitted on February 7, 2024 and was still active at the time of the inspection. A treatment plan was completed on February 7, 2024.
Client #9 was admitted on February 27, 2024 and was discharged on March 7, 2024. A treatment plan was completed on February 27, 2024.
These findings were discussed with facility staff during the inspection process.
This is a repeat citation from the October 23, 2023 licensing inspection.
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Plan of Correction
Clients #2, #3, #4, #5, and #9 were immediately scheduled for an individual session with their counselor to create a new master treatment plan that includes their long and short-term goals. Master Treatment Plans are part of the initial intake package and are usually completed with every client upon intake.
The Clinical Supervisor will re-educate staff on Master Treatment Plans and Treatment Plan Updates during the weekly census meeting, including proper documentation of long and short-term goals. Counselors have been educated on acceptable sober support systems for individual clients.
The clinical Director will monitor client charts monthly to ensure proper documentation is being done accurately and on time.
Responsible for these actions: Clinical Director, Clinical Supervisors, and Counselors.
Time frame: Immediate action
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 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 five out of seven applicable client records reviewed.
Client #3 was admitted on February 6, 2024 and was still active at the time of the inspection. A treatment plan update was completed on February 6, 2024 and the next update was due no later than April 6, 2024; however, no update was completed at the time of the inspection.
Client #4 was admitted on December 1, 2023 , and was still active at the time of the inspection. A treatment plan update was completed on December 1, 2023 , and the next update was due no later than February 1, 2024; however no update was documented at the time of the inspection.
Client #5 was admitted on February 7, 2024 and was still active at the time of the inspection. A treatment plan update was completed on February 7, 2024 and the next update was due no later than April 7, 2024; however, no update was documented at the time of the inspection.
Client #6 was admitted on September 25, 2023 and discharged on February 5, 2024 . A treatment plan update was completed on September 25, 2023 and the next update was due no later than November 25, 2023; however, no update was document at the time of the inspection.
Client #8 was admitted on August 7, 2023 and was discharged on January 5, 2024. A treatment plan update was completed on October 7, 2023 and the next update was due no later than December 7, 2023; however, no update was documented at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the October 23, 2023, October 25, 2022 and November 19, 2021 licensing inspection.
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Plan of Correction
The Clinical Supervisor has re-trained counselors on the importance of proper documentation and timely filing.
Clinical supervisor(s) will check client charts weekly to ensure Master treatment plans and treatment plan updates are signed, dated, and returned by the medical director promptly.
The Clinical Director will check charts monthly to ensure treatment plans are documented correctly and on time.
Responsible for these actions: Clinical Director, Clinical Supervisors, and Counselors.
Timeframe: Immediate action
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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 three of four applicable client records reviewed, the facility failed to provide follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a follow-up to occur 7 days after discharge.
Client # 6 was admitted September 25, 2023 and was discharged on February 5, 2024 .There was no follow-up information available in the client record.
Client #8 was admitted on August 7, 2023 and was discharged on January 5, 2024. There was no follow-up information available in the client record.
Client#9 was admitted on February 27, 2024 and was discharged on March 7, 2024. There was no follow up information available in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor has re-trained counselors on the importance of proper documentation and timely filing.
Clinical supervisor(s) will check client charts weekly to ensure that follow-up information is in accordance with ABT's policy and procedures.
The Clinical Director will check charts monthly to ensure follow-ups are documented with-in 7 days from discharge as per ABT's policy.
Responsible for these actions: Clinical Director, Clinical Supervisors, and Counselors.
Timeframe: Immediate action
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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 staff training records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for treatment plan updates were submitted and approved by the Department for the October 23, 2023, October 25, 2022 and November 19, 2021 annual licensing inspections.Treatment plan updates was again found to be a deficiency in the May 6, 2024 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Updated treatment plans were submitted and approved after the last inspection. The clinical director misunderstood the instructions and believed "strength" was an acceptable description of PIRs support outside treatment. The word support has been added to the treatment plan templates, in addition to PIRs strengths.
Clinical supervisor(s) will check client charts weekly to ensure the correct treatment plan templates are being used. The clinical director will check charts monthly to ensure treatment plans are documented correctly and on time.
Responsible for these actions: Clinical Director, Clinical Supervisors, and Counselors.
Timeframe: Immediate action |