INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 5, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Evolve Addiction Recovery 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 (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 client records, the facility failed to obtain a consent to release information form prior to releasing information. There was no consent to release information forms for the funding source or it was signed after billing had started in three out of seven records reviewed. Facility staff confirmed billing had occurred.Client #1 was admitted on July 10, 2024 and was still active at the time of the inspection. There was no release of information for the funding source.Client #2 was admitted on July 1, 2024 and was still active at the time of the inspection. There was no release of information for the funding source.Client #6 was admitted on July 2, 2024 and was still active at the time of the inspection. The release of information for the funding source was dated July 22, 2024.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
According to code 709.28 (c) confidentiality; the project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
Evolve Addiction Recovery, LLC and its staff will obtain a consent from the client to release information prior to releasing information at all times for all releases including, but not limited to funding sources.
Responsible party: All Evolve Addiction Recovery, LLC evaluation and counseling staff.
The Executive/Clinical Director will assure that this is being done by reviewing client charts on a daily basis.
Corrective date is 9/5/2024. |
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 document that client orientation had taken place 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
According to code 709.91(b)(2)(i) 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.
Evolve Addiction Recovery, LLC (EAR) and its staff will assure that each client receives client orientation paperwork that adheres to the regulation. A signed consent by the client will be done at time of evaluation to show that the client consents to receiving such orientation paperwork.
That consent was added to EAR's EHR the day of inspection. It reads as follows:
Intake and Admission Disclosure
I, "CLIENT NAME", consent that criteria for admission, treatment, completion, and discharge were disclosed to me. I was given a copy of the Evolve Addiction Recovery, LLC. Client Handbook that goes over client orientation to the project which shall include, but is not limited to, a familiarization with the following: Project policies, Hours of operation, Fee schedule, and Services provided.
Each client that was already enrolled prior to inspection will sign the consent and given that orientation paperwork.
Responsible party: All EAR evaluation and counseling staff.
The Executive Director/Clinical Director will be monitoring client charts daily to assure that this is being done at time of evaluation.
Correction date: 9/5/2024 |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in seven out of seven applicable records reviewed. The facility's policy and procedures manual states that case consultations must be completed quarterly.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
According to code 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: (8) Case consultation notes.
Evolve Addiction Recovery, LLC staff will document a case consultation within guidelines established by our policy and procedures manual that states that case consultations must be completed quarterly.
Case consultations will be done for all clients at time of their treatment plan update and earlier if applicable.
Case consultations will be done for all clients that were active prior to inspection
Responsible party: All Evolve Addiction Recovery, LLC counseling staff.
The Executive Director/Clinical Director will assure that these are being performed.
Correction date: 9/20/2024 |