INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 11, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Pathway to Recovery Counseling and Educational 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(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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one out of seven records reviewed.
Client #3 was admitted on September 30, 2024 and was still active at the time of the inspection. The client record documented contact with a pharmacy on October 28, 2024; however, there was no documentation that the facility obtained an informed and voluntary consent for the release of information for the pharmacy.
This is repeat citation from the January 10, 2024 and December 20, 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On December 12, 2024 the Clinical Director reviewed the findings of the DDAP Licensing Audit during weekly Treatment Team Meeting. In response to the citation a release of information was obtained from the client in order to bring the chart up to compliance. It was then reviewed with the counselors the importance of remaining compliant with confidentiality which included, but is not limited to obtaining an appropriate Release of Information. The counselors were trained on new releases that will be required in all charts which includes a Pharmacy Release for anyone that is seeing the doctor and a Pennsylvania Department of Human Services release for all clients to assure compliance when checking insurances. Counselors were advised to continue obtaining insurance and emergency contact releases as well. The Clinical Director will review all new clients charts to assure that all necessary releases were obtained and review on a monthly basis to confirm that compliance is being maintained in regards to confidentiality. This is effective 12/16/2024 |
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 two out of five applicable records reviewed.
Client #4 was admitted on February 2, 2024 and was discharged on May 31, 2024. A treatment plan update was completed on March 20, 2024 and the next update was due no later than May 20, 2024; however, there is no documentation that one was completed.
Client #6 was admitted on May 3, 2024 and was discharged on July 22, 2024. A treatment plan update was completed on May 20, 2024 and the next update was due no later than July 20, 2024; however, it was completed on July 22, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On December 12, 2024 the Clinical Director reviewed the findings of the DDAP Licensing Audit during weekly Treatment Team Meeting. It was reviewed with the counselors the importance of remaining compliant with the 60 day Treatment Plan Review time frame. The counselors were trained on completing all treatment plan reviews within the 60 day time frame even when client is not present. Counselors were instructed to review the Treatment Plan with the client when he/she returned to services should the client not be present for the due date. The clinical director will oversee compliance of Treatment Plan Review updates by regularly auditing charts on a monthly basis. Counselors will also continue to receive a "to do list" for each client's session which will include Treatment Plan updates within the 60 day time frame. This "to do list" will be monitored by the Clinical Director & counselor. This is effective 12/16/2024. |
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 treatment plan in three out of six applicable records reviewed.
Client #2 was admitted on October 4, 2024 and was still active at the time of the inspection. The treatment plan dated October 18, 2024, indicated one hour of individual therapy per week. There was no documentation of the client receiving individual therapy the weeks of October 21, November 4 and November 25, 2024.
Client #5 was admitted on July 31, 2024 and discharged on October 2, 2024. The treatment plan dated August 5, 2024, indicated one hour of individual therapy per week. There was no documentation that the client received individual therapy the weeks of August 12, 26, September 2 and September 23, 2024.
Client #6 was admitted on May 3, 2024 and discharged on July 22, 2024. The treatment plan dated May 20, 2024, indicated one hour of individual therapy per week. There was no documentation that the client received individual therapy the weeks of June 3, July 1 and July 15, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On December 12, 2024 the Clinical Director reviewed the findings of the DDAP Licensing Audit during weekly Treatment Team Meeting. It was reviewed with the counselor the importance of following the Treatment Plan of the client. Counselors were trained on a more Person Centered approach to the development of the treatment plan, which included the frequency that the client is able and willing to attend individual sessions. Counselors were advised during this training to avoid placing "weekly individual sessions" as a blanket statement if the client is unable to attend weekly. Counselors were also trained at this point to assure that amount and frequency of individual and groups sessions remained in the treatment plan. In order to assist with assuring the client is being scheduled according to the treatment plan, the counselors were encouraged to use re-occurring appointments in the EHR system. If for any reason the client is unable to be scheduled according to the treatment plan it will be documented in a note within the chart with an explanation as to why the appointment could not be made. The Clinical Director will oversee compliance of Master Treatment Plan & Treatment Plan Reviews by regularly auditing the charts on a monthly basis. The Clinical Director will also sign off on all Master Treatment Plans & Treatment Plan Reviews. This is effective 12/16/2024. |
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 client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for ensuring confidentiality in client records was submitted and approved by the Department for the December 20, 2022, and January 10, 2024, annual licensing inspections. Ensuring confidentiality was again found to be a deficiency in the December 11, 2024, licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On December 17, 2024 the Clinical Director met with the President & CEO, Mental Health Clinical Supervisor, & Lead Counselor during the monthly Quality Assurance Meeting to discuss the failure to comply with plans of correction in regards to confidentiality. It was reviewed that the agency remains non compliant with 709.28(c) Confidentiality due to 3 consecutive citations regarding the same issue and has received an Administrative Citation. All 3 citations were reviewed and a plan was discussed that can be implemented to assure that all plans of corrections are being followed. The Quality Assurance team has agreed to pull a minimum of 5 charts monthly for the sole purpose of auditing and reviewing compliance in regards to all regulations and all plans of correction. This will be documented during each Quality Assurance Meeting. The Clinical Director will pull the 5 charts that are to be reviewed and oversee the documentation of the chart audits . This is effective 12/17/2024. |