INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on July 22-23, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, New Directions Treatment Services 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 (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
Based on a physical plant inspection, the facility failed to secure hard copy client records within locked storage containers. The facility had filing cabinets containing client records that were unattended and unlocked. In addition, client identifying information was discovered in an unattended counselor's desk drawer.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 8/06/2024, the Program Director reminded staff during the weekly team meeting of the confidentiality requirement to secure clinical documentation in locked storage containers when the record storage area is unattended. The Clinical Supervisor will be responsible for ongoing compliance with the regulatory requirements through regular reminders to the clinical staff during weekly team meetings and individual clinical supervision. The HR Manager will ensure that confidential client information is not left unsecured in any unoccupied location at the facility. |
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 in one out of seven records reviewed.
Client #5 was admitted on April 20, 2016 and discharged on December 5, 2023. There was no release of information form for a funding source and lab in the client's record. Facility confirmed billing and laboratory services had occurred.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 8/06/2024, the Program Director reminded staff during the weekly team meeting of the requirement to obtain the client's Consent to Release Confidential information to vendors providing laboratory services and to funding sources providing treatment funding prior to communicating client information to laboratory staff and funding entities. Ongoing compliance will be the responsibility of the QA Manager through review of Consent to Release Confidential Information documentation during random and scheduled audits of the clinical record. |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on the review of client records, the facility failed to document a completed consent to release information form to include purpose of disclosure in three out of seven records reviewed.
Client #1 was admitted on August 24, 2020 and was still active at the time of the inspection. The form was dated August 17, 2023 to an emergency contact.
Client #2 was admitted on January 20, 2021 and was still active at the time of the inspection. Two forms dated January 29, 2024 were to a family member and the funding source.
Client #3 was admitted on January 24, 2024 and was still active at the time of the inspection. The form was dated February 7, 2024 to another treatment facility.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 8/13/24, the Program Director reminded the clinical staff to ensure that the purpose of disclosure is included on all Consents to Release Confidential Information signed by the clients. Ongoing compliance with the regulation will be the responsibility of the QA Manager through a review of the Consent To Release Confidential Information documentation during random and scheduled audits of the clinical records. |
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 shall be offered to the client in three out of seven records reviewed.
Client #1 was admitted on August 24, 2020 and was still active at the time of the inspection. The forms were dated August 17, 2023 to a lab and funding source.
Client #3 was admitted on January 24, 2024 and was still at the time of the inspection. The form was dated January 24, 2024 to probation.
Client #7 was admitted on December 24, 2019 and was still active at the time of the inspection. The form was dated December 5, 2023 to a lab.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 8/13/2024. Staff was reminded by the Program Director of the requirement to document that the client has been offered a copy of any release they sign. The QA Manager will be responsible for ongoing compliance with the regulation through random review of the releases during random and scheduled record audits.
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709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
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Observations
Based on direct observation and staff interviews, the facility failed to maintain a data collection and recordkeeping system that allowed for efficient retrieval of data needed for the annual licensing inspection. Requested required documentation took up to two days to provide to the auditors. In addition, staff expressed to auditors an inability to print documentation from the electronic system, in a timely manner, which included parts of client's medical record.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of August 21st 2024, Clinical and Medical staff were notified that all electronic clinical documentation must be printed upon completion and must be stored in a hard copy file that will be readily available for a minimum of four years following the discharge of the client. Ongoing compliance with the regulation will be the responsibility of the QA Manager and the Nursing Director who will monitor timeliness of completion of the hard copy files through regular audits of a random sample of all Clinical and Medical records maintained at the facility. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of internal unusual incident documentation, the facility failed to inform the Department of an unusual incident within the required three days. It was discovered that the facility had two unusual incidents on September 11, 2023 and December 19, 2023 which involved presence of ambulance personnel.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 8/13/24, the Nursing Director reviewed the regulatory requirement to report the presence of ambulance personnel as an Unusual Incident with staff. Medical staff will be responsible for completing an Incident Report and submitting the report to the Facility Director before the end of the business day whenever ambulance personnel present to the clinic. The Facility Director or his/her designee will submit and Unusual Incident Report to the department within the required Time Frame. Ongoing compliance with the regulation will be the responsibility of the Facility Director through timely submission of Unusual Incident reports to the Department. |
715.7(b) LICENSURE Dispensing or Administering Staffing
(b) Dispensing time shall be prorated for patient census. There shall be sufficient dispensing staff to ensure that all patients are medicated within 15 minutes of arrival at the dispensing area.
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Observations
Based on a review of documentation and staff interviews, the facility failed to ensure that all patients are medicated within 15 minutes of arrival at the dispensing area. Documentation of a patient grievance dated July 10, 2024 indicated dosing times exceed an hour.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 8/13/2024, the Nursing Director reviewed and posted the dosing protocols to be used in the event of power failure/EMR malfunction/dropped internet signal or other incident that prevents the use of the automated dispensing system with the dispensing staff. Manual dosing will begin within five minutes of any dispensing system failure to ensure that all clients receive medication within no more than fifteen minutes of entering the clinic area. Additional staff will be scheduled and available to open an extra dosing window during more popular dosing days and times. Scheduled dosing windows and/or days will be implemented for clients receiving extended take homes who only have to attend the clinic once or twice per month.Ongoing compliance with the regulation will be the responsibility of the Nursing Director through random audit of the dispensing room recordings. |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on the review of patient records, the facility failed to verify an individual's identity and/or emergency contact in two out of seven records reviewed.
Patient #3 was admitted on January 24, 2024 and was still active at the time of the inspection. There was no documentation of verification of identity and emergency contact in the client's record.
Patient #5 was admitted on April 20, 2016 and discharged on December 5, 2023. There was no documentation of an emergency contact in the client's record.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
During weekly team meeting on 08/13/2024, the Program Director reminded clinical and medical staff of the requirement to retain documentation used to verify client identity in the record. As of 08/22/2024, Intake staff will scan the Photo Identification used to verify client identity into the clinical record. Intake staff will be responsible for obtaining an Emergency Contact with a signed Consent to Release protected health information from each applicant seeking admission to treatment. The Clinical Supervisor will be responsible for ensuring compliance with the regulation through a review of all Intake documentation, prior to the client's admission to treatment. Ongoing compliance with the requirement will be the responsibility of the Clinical Supervisor through random record review and during Individual Supervision with clinicians.
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715.10(d) LICENSURE Pregnant patients
(d) Within 3 months after termination of pregnancy, the narcotic treatment physician shall enter an evaluation of the patient 's treatment status into her record and state whether she should remain in comprehensive maintenance treatment or receive detoxification treatment.
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Observations
Based on a review of patient records, the facility failed to document an evaluation by a narcotic treatment physician of the patient's treatment status within three months post pregnancy in one out of one applicable record.
Patient #1 was admitted on August 24, 2020 and was still active at the time of the inspection.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 8/19/2024, the Nursing Director will be responsible for alerting the Narcotic Treatment Physician to document an evaluation of the patient's treatment status within three months post pregnancy for all pregnant women. Ongoing compliance with the regulation will be the responsibility of the Nursing Director through a review of the Narcotic Treatment Provider's documentation of the post pregnancy evaluation for all pregnant women admitted to the program without physiological dependence .
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715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on the review of patient records, the facility failed to complete an initial drug-screening urinalysis for each prospective patient in one out of one applicable record.
Patient #3 was admitted on January 24, 2024 and was still active at the time of the inspection.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 8/23/2024, the Facility Director will remind medical and clinical staff that an initial drug-screening urinalysis must be completed for every prospective patient, including patients transferred from another Opioid Treatment Program, prior to admission. Ongoing compliance will be the responsibility of the Clinical Supervisor through a review of all Intake documentation for new admissions prior to admission to the program.
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715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
Based on observations during medication administration, the facility failed to ensure that agent was ingested by the patient, as one patient did not speak following being dosed. The facility's policy and procedures manual states "Patient must speak with the nurse on duty before leaving the dispensing area".
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 8/22/2024, The Nursing Director reviewed dosing protocols with dispensing staff to remind them of the requirement that the patient speaks with staff after ingesting the medication. Dosing procedures have been posted at each dispensing station. Ongoing compliance with the requirement will be the responsibility of the Nursing Director who will monitor compliance through random direct observation of medication dispensing procedures on an ongoing basis. |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of patient records, the facility failed to provide patients with 2.5 hours of psychotherapy per month during the patient's first two years of treatment, one hour of which shall be individual psychotherapy, in one out of two applicable records.
Client #3 was admitted on January 24, 2024 was still active at the time of the inspection. In April and June 2024, the client had one sixty minute appointment during each month in which they did not show. In May 2024, the client did not show for a sixty minute appointment on May 6, 2024 and attended a sixty minute individual session on May 13, 2024.
The findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the July 29, 2021, July 19, 2022 and July 25, 2023 annual licensing inspections.
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Plan of Correction
As of 08/22/2024, the patient Consent to Methadone Treatment will be revised to include patient agreement to attend to a minimum of 2.5 hour of counseling per month for the first two years in treatment, 1.0 hours of counseling per month between two years and four years in treatment and 1.0 hour of counseling per month after four years of treatment in order to remain in the program. Meeting counseling attendance requirements will be included as a goal in all Treatment Plans throughout treatment. The Clinicians will be responsible for implementing interventions to ensure patient compliance with the counseling attendance requirements in the treatment plans. Ongoing compliance with meeting the regulatory requirement will be the responsibility of the Clinical Supervisor and will be monitored and reported to clinicians and the Clinical Supervisor by the QA Manager on a monthly basis. |
715.19(2) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(2) A narcotic treatment program shall provide each patient at least 1 hour per month of group or individual psychotherapy during the third and fourth year of treatment. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of patient records, the facility failed to provide patients with one hour per month of therapy during the third and fourth year of treatment in three out of three applicable records.
Patient #1 was admitted on August 24, 2020 and was still active at the time of the inspection. In April and June 2024, the patient did not receive any therapy sessions.
Patient #2 was admitted on January 20, 2021 and was still active at the time of the inspection. In June 2024, the patient did not receive any therapy sessions.
Patient #7 was admitted on December 24. 2-10 and was still active at the time of the inspection. In May 2024, the patient did not receive any therapy sessions.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 08/22/2024, the patient Consent to Methadone Treatment will be revised to include patient agreement to attend to a minimum of 2.5 hour of counseling per month for the first two years in treatment, 1.0 hours of counseling per month between two years and four years in treatment and 1.0 hour of counseling per month after four years of treatment in order to remain in the program. Meeting counseling attendance requirements will be included as a goal in all Treatment Plans throughout treatment. The Clinicians will be responsible for implementing interventions to ensure patient compliance with the counseling attendance requirements in the treatment plans. Ongoing compliance with meeting the regulatory requirement will be the responsibility of the Clinical Supervisor and will be monitored and reported to clinicians and the Clinical Supervisor by the QA Manager on a monthly basis. |
715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the facility failed to document the notification of the previous narcotic treatment program of the admission and initial dose of the patient in one out of one applicable record.
Patient #3 was admitted on January 24, 2024 and was still active at the time of the inspection.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 8/23/2024, the Program Director will remind staff of the requirements to document notification to the transferring program of the admission of the patient and the date of the initial dose received by the patient when a patient transfers from another narcotic treatment provider. The Transfer In Documentation Packet that includes the confirmation of the Patient Admission and the Date of Initial dose will be provided to staff. Ongoing compliance with the documentation regulations will be the responsibility of the Clinical Supervisor who will review the records of all patient transfers to ensure all documentation required is included in the record. |
715.22(b) LICENSURE Patient grievance procedures
(b) The procedure shall permit aggrieved patients a full and fair opportunity to be heard, to question and confront persons and evidence used against them and to have a fair review of their grievances by the narcotic treatment program director. If the grievance is filed against the narcotic treatment program director, the review of the case shall be conducted by either a multi-representative group of the narcotic treatment program or a subcommittee of the governing body instituted for the express purposes of grievance adjudication.
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Observations
Based on the review of documentation, the facility failed to provide written documentation of the results of client submitted grievances between the timeframe of November 16, 2023 through July 17, 2024. One grievance was submitted in November 2023 and fifteen were submitted in July 2024.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 8/13/2024, the Facility Director reviewed with staff the Complaint and Grievance Procedures that require that the outcomes of the investigation/resolution of any client complaint or grievance submitted is documented on the complaint form submitted by the client. Ongoing compliance will be the responsibility of the QA Manager who will review documentation of all complaints/grievances on an ongoing basis.
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715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on the review of patient records, the facility failed to document an annual physical examination by the narcotic treatment physician in one out of three applicable records.
Patient #2 was admitted on January 20, 2021 and was still active at the time of the inspection. An annual physical examination was conducted on February 14, 2024. There was no documentation of a physical examination occurring in 2023.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 08/23/2024, the Nursing Director or his/her designee will create a tracking list of the Annual Physical Due Dates and will schedule all annual physical examinations on an on-going basis. Reminders of upcoming appointments will be will be provided to all clients by dispensing staff. Interventions will be implemented for patients who do not keep scheduled appointments and will remain in place until the regulatory requirement has been met. Ongoing compliance with the regulation will be the responsibility of the Nursing Supervisor who will monitor patient appointment attendance to ensure the requirement has been met before the end of each month.
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715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on a review of patient records, the facility failed to document an annual clinical evaluation, that has been reviewed, dated and signed by the medical director, within the regulatory timeframe in three out of three applicable records reviewed.
Patient #1 was admitted on August 24, 2020 and was still active at the time of the inspection. The annual clinical evaluation dated August 17, 2023 did not include a signature by the medical director.
Patient # 2 was admitted on January 20, 2021 and was still active at the time of the inspection. The annual clinical evaluation was dated January 30, 2024. There was no documentation of a clinical evaluation occurring in 2023.
Patient #7 was admitted on December 24, 2019 and was still active at the time of the inspection. The annual clinical evaluation was dated December 5, 2023 but did not include a signature by the medical director.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 8/23/2024, the Facility Director will remind the clinicians of the regulatory requirement to document the Annual Review every year throughout treatment. Ongoing compliance of the regulation will be the responsibility of the Clinical Supervisor and the QA Manager through random review of the Annual Review documents included in the record and during individual clinical supervision. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to include documentation of a preliminary treatment and rehabilitation plan during intake procedures in two out of two applicable records.
Client #3 was admitted on January 24, 2024 and was still active at the time of the inspection.
Client #4 was admitted on May 2, 2024 and was still active at the time of the inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 8/23/2024, the facility Director will remind staff of the regulatory requirement that the Initial/Preliminary Treatment Plan must be completed during the Intake at the time of admission to treatment. Ongoing compliance will be the responsibility of the Clinical Supervisor during random record review and during individual supervision with the clinical staff. |
709.92(a) 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:
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Observations
Based on a review of client records, the facility failed to develop an individual treatment and rehabilitation plan with the client in one out of two applicable records reviewed.
Client # 4 was admitted on May 2, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was dated by the client on May 9, 2024 but the body of the document was blank.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 8/23/2024, the Facility Director will remind staff of the regulatory requirement that the individual Treatment Plan must be completed within thirty days of admission to the program. Ongoing compliance with the regulation will be the responsibility of the Clinical Supervisor and the QA Manager through random record review and during individual supervision with the clinical staff.
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709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure that the clients received counseling services according to their individual comprehensive treatment plan in four out of six records reviewed.
Client #1 was admitted on August 24, 2020 and was still active at the time of the inspection. A treatment plan, dated May 21, 2024, indicated weekly individual sessions. The progress notes indicated that the client did not receive any individual sessions from May 22, 2024 through the date of the inspection.
Client #2 was admitted on January 20, 2021 and was still active at the time of the inspection. Treatment plans dated March 26, 2024 and May 21, 2024, indicated weekly individual sessions. The progress notes indicated that the client did not receive any individual sessions from March 26 -April 21, April 23 - May 20, and May 22, 2024 through the date of the inspection.
Client #3 was admitted on January 24, 2024 and was still active at the time of the inspection. A treatment plan, dated March 28, 2024, indicated 2.5 hours per month with group sessions weekly. The progress notes indicated that the client did not receive any sessions between March 29 - April 29, May 14 - June 17, June19 - July 1 and July 3 through the date of the inspection.
Client #7 was admitted on December 24, 2019 and was still active at the time of the inspection. A treatment plan dated April 30, 2024 indicated monthly individual sessions. The progress notes indicated that the client did not receive any individual sessions in May 2024.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 8/23/2024, the Facility Director will remind the clinicians that the frequency of services recommended and included in the Treatment Plans must be provided exactly as outlined in the Treatment Plan. Ongoing compliance of the regulation will be the responsibility of the Clinical Supervisor through random review of the treatment plans and services provided in the clinical record and during individual supervision. |
709.93(a)(3) 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:
(3) Record of services provided.
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Observations
Based on the review of client records, the facility failed to provide a complete client record, which shall include a record of service in seven out of seven records reviewed.
Client #1 was admitted on August 24, 2020 and was still active at the time of the inspection.
Client #2 was admitted on January 20, 2021 and was still active at the time of the inspection.
Client #3 was admitted on January 24, 2024 and was still active at the time of the inspection.
Client #4 was admitted on May 2, 2024 and was still active at the time of the inspection.
Client #5 was admitted on April 20, 2016 and discharged on December 5, 2023.
Client #6 was admitted on February 28, 2018 and discharged on August 2, 2023.
Client #7 was admitted on December 24, 2019 and was still active at the time of the inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 08/23/2024, Clinicians will be provided with a Record of Services template to document the services provided with the date and duration of the service that will be included in the hard copy of the record.
Ongoing compliance with the regulation will be the responsibility of the QA Manager through random record review during regular QA audits of the clinical records.
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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 the review of client records, the facility failed to provide a complete client record, which shall include a case consultation in accordance with the facility's policy and procedures manual in three out of four records reviewed. The policy and procedures manual states a case consultation will occur within the first 90 days and annually thereafter.
Client #2 was admitted on January 20, 2021 and was still active at the time of the inspection. A case consultation occurred on January 29, 2024. There was no documentation of a case consultation occurring in 2023.
Client #3 was admitted on January 24, 2024 and was still active at the time of the inspection. Documentation showed the first case consultation occurred on July 3, 2024.
Client #7 was admitted on December 24, 2019 and was still active at the time of the inspection. There was no documentation of a case consultation in the client's record.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
During the Treatment Team Meeting on 8/13/2024, the Facility Director reminded the clinicians of the regulatory requirement to document Case Consultations in the record every 90 days for the first year of treatment and annually thereafter. Ongoing compliance of the regulation will be the responsibility of the Clinical Supervisor and the QA Manager through random review of the Case Consultation Notes that are included in the record and during individual supervision. |
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 the review of client records, the facility failed to provide a complete client record, which shall include follow-up information in accordance with the facility's policy and procedure manual in one out of two applicable records reviewed. The policy and procedures manual states follow-up shall occur within seven days of discharge.
Client #6 was admitted on February 28, 2018 and discharged on August 2, 2023. There was no documentation of follow-up in the client's record.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 8/13/2024 the Facility Director reminded staff to document Follow Up contacts in the Discharge Summary within seven days of patient discharge. Staff was advised if the patient cannot be reached, the attempt to reach the patient should be documented in the Follow Up Note. Ongoing compliance will be the responsibility of the Clinical Supervisor during the review of discharged client records before closure of the record.
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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 patient records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for failing to provide patients with 2.5 hours of psychotherapy per month during the patient's first two years of treatment were submitted and approved by the Department for the July 29, 2021, July 19, 2022 and July 25, 2023 annual licensing inspections. Psychotherapy requirements per month were again found to be a deficiency in the July 23, 2024 licensing inspection.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
By 8/24/2024, the Facility Director will meet with the Treatment Team Supervisors to review the Plans of Correction approved by the department in 2021, 2022 and 2023 and to address implementation of the revised Plans of Correction for 2024. The Clinical Supervisors will coordinate with the QA Manager and will be responsible for ongoing compliance with meeting the regulatory requirements through monthly record of service audits and sharing the audit results with staff during group and individual Clinical Supervision. |