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Pennsylvania Department of Health
Inspection Results

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LIBERATION WAY, LLC
70-90 WEST AFTON AVENUE
YARDLEY, PA 19067

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Survey conducted on 03/30/2017

INITIAL COMMENTS
 
This report is a result of an on-site licensure renewal inspection conducted on March 30, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Liberation Way, 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:
 
Plan of Correction

704.2(b)  LICENSURE Staffing Plan

704.2. Compliance plan. (b) The plan documenting the qualifications and training of staff shall be presented to Department licensing representatives at the time of the project's site visit.
Observations
A licensing renewal inspection was conducted for the facility on March 30, 2017. The facility failed to present a complete and accurate plan including all staff members, qualifications of staff members, training of staff members, facility work hours, and caseload counts during the annual inspection. These findings were reviewed with the licensing staff during the licensing process.
 
Plan of Correction
Personnel changes were made between the time of the pre-submission and actual inspection date.



New forms were completed and forwarded to DDAP.



In the future Human Resources will assist with the completion of the Staffing Requirements Facility Summary Report form (SRFSR).



As well should any changes occur between the time of the presubmission of the SRFSR form and date of the inspection an updated SRFSR fotm will be forwarded to DDAP.

704.6(c)  LICENSURE Core Curriculum - Supervisor Training

704.6. Qualifications for the position of clinical supervisor. (c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
Observations
One personnel record was reviewed for the clinical supervisor position on March 29-30, 2017. The facility failed to document the completion of a Department-approved core curriculum in clinical supervision for employee record # 3. Employee # 3 was hired by the facility on 6/20/15 as a clinical supervisor. Documentation in the employee's record indicated that the employee completed a core curriculum in clinical supervision on 6/24/16. This core curriculum was not provided by the Department and the facility failed to obtain prior approval from the Department. This finding was reviewed with facility staff during the licensing process.
 
Plan of Correction
In 2016 Employee #3 completed approved clinical supervision training through The Center for Credentialing and Education and affiliate of the National Board of Certified Counselors, Inc. NBCC is an organization deemed to provide independent training. The actual training was provided by the University of North Carolina.



We failed to obtained prior approval and continue to experience difficulty in obtaining a curriculum to provide to the DDAP- Department of Training.



In order to correct this action Employee #3 was directed to enroll in the upcoming DDAP approved Clinical Supervision Course in June, 2017. She will complete the application, enroll and attend.



To ensure that this will not happen again Human Resources if hiring or promoting an individual to the role of clinical supervision, HR will check qualifications and arrange the appropriate training if necessary and obtain prior approval.

704.9(a)  LICENSURE Counselor Asst Supervision

704.9. Supervision of counselor assistant. (a) Supervision. A counselor assistant shall be supervised by a full-time clinical supervisor or counselor who meets the qualifications in 704.6 or 704.7 (relating to qualifications for the position of clinical supervisor; and qualifications for the position of counselor).
Observations
Two personnel records were reviewed for the counselor assistant position on March 29-30, 2017. The facility failed to ensure that employee # 9 was supervised by a full-time clinical supervisor or counselor during the period of direct observation. Employee # 9 was hired by the facility on 12/7/16 as a high school diploma level counselor assistant. The employee was not supervised by a full-time clinical supervisor or counselor. This finding was reviewed with facility staff during the licensing process.
 
Plan of Correction
Will keep Employee #9 in their current position as counselor assistant.



Employee #9 will be provided with the a full time counselor or clinical supervisor to insure that his counselor assistant are provided with a full time supervisor in accordance with the regulations.



To insure that this does not occur again Human Resources will screen all new hires that qualify for counselor assistant and assign them a full time counselor or clinical supervisor to provide them with supervision in accordance with the regulations.

704.9(c)  LICENSURE Supervised Period

704.9. Supervision of counselor assistant. (c) Supervised period. (1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment. (2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment. (3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment. (4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment. (5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
Observations
Two personnel records were reviewed for the counselor assistant position on March 29-30, 2017. The facility failed to document the provision of close supervision and/or direct observation for employee records # 8 and 9. Employee # 8 was hired by the facility on 8/10/15 as a high school diploma level counselor assistant. The employee required direct observation for the first 3 months as a counselor assistant, and close supervision for the next 9 months. The period of close supervision was to include an additional hour of direct observation at least once a week. Weekly supervision notes were reviewed for the period 2/2/16 - 8/12/16. The facility failed to document supervision for the following weeks: - 4/22/16- 4/29/16- 5/13/16- 5/27/16- 6/24/16- 7/8/16- 7/22/16- 7/29/16- 8/5/16- 8/12/16In addition, the facility failed to demonstrate that weekly close supervision (for the period following the first 3 months) include an additional hour of direct observation at least once a week. Employee # 9 was hired by the facility on 12/7/16 as a high school diploma level counselor assistant. The employee requires direct observation for the first 3 months as a counselor assistant, and close supervision for the next 9 months. The period of close supervision is to include an additional hour of direct observation at least once a week. Weekly supervision notes were reviewed for the period of 12/19/16 - 3/3/17. The facility failed to demonstrate that direct observation was conducted during this timeframe. This finding was reviewed with facility staff during the licensing inspection.
 
Plan of Correction
Will keep employees 8 & 9 in their current position as counselor assistant.



They will be provided with necessary direct observation beginning on 5/17/2017 through 8/17/2017; at which time they will begin close supervision.



Moving forward Human Resources will screen all potential candidates to insure that they meet the requirements of counsellor or insure that they as counselor assistants are provided supervision in accordance with the regulations

704.10  LICENSURE Counselor Asst Promotion

704.10. Promotion of counselor assistant. (a) A counselor assistant who satisfactorily completes one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) may be promoted to the position of counselor. (b) A counselor assistant shall document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year. (c) A counselor assistant shall meet the requirements for counselor within 5 years of employment. A counselor assistant who has accumulated less than 7,500 hours of employment during the first 5 years of employment will have 2 additional years to meet the requirements for counselor. (d) A counselor assistant who cannot meet the time requirements in subsection (c) may submit to the Department a written petition requesting an exception. The petition shall describe the circumstances that make compliance with subsection (c) impracticable and shall be approved by both the clinical supervisor or lead counselor and the project director. Granting of the petition will be within the discretion of the Department.
Observations
Two personnel records were reviewed for the counselor assistant position on March 29-30, 2017. Employee # 8 was hired by the facility on 8/10/15 as a high school diploma level counselor assistant. Upon the completion of the 2016 calendar year, the employee was required to document to the facility that he is working toward counselor status. This documentation was not documented in the employee's record. This finding was reviewed with facility staff during the licensing inspection.
 
Plan of Correction
Employee #8 will remain in his current position. We would like to take this opportunity as we had with Ms. Nelson share with you that this client has had a year filled with hardships. The loss of his parent, birth of a new child, financial problems.



We will meet with #8 before May 26, 2017 to assist him making plans and document this interaction in his personnel record.



To insure that #8 is working towards counselor status training, courses completed must be presented to his supervisor and HR. HR will provide reminders to (him)that courses are due or there is a lack of activity..



We will need to insure that he is school



In the event that this employee cannot meet this requirement we may consider needing place him in a new position

704.11(a)  LICENSURE Staff Development Procedure

704.11. Staff development program. (a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
Observations
Administrative records pertaining to the facility's staff development program were reviewed on March 29, 2017. The facility's current training year is January - December 2017, as reported by the facility. The facility failed to provide documentation of an assessment of staff training needs for the current training year. In addition, the facility failed to document an annual evaluation of the overall training plan for the 2016 training year. This finding was reviewed with facility staff during the licensing inspection.
 
Plan of Correction
Policy will be revised regarding Staff Training by 5/30/2017.



Human Resources will complete an evaluation of the current staff training needs for the current training year Jan. 2017-December 31, 2017. This will be accomplished by reviewing the annual reviews completed which each employee identified their training needs as well as contacting the rest of the staff whose annual reviews are pending and having them identify their training needs.

Facility Director, Project Directors, Clinical Supervisors will conduct an annual evaluation of the trainings completed during the 2017 training year. This is an annual document where we will evaluate the trainings that staff completed each year. This document will highlight trainings offered during the training year, the opinion of the staff of the trainings, and will result in well-organized training plan for the following year.

The Facility Director and Project Directors along with input from Compliance and Human Resources will review and assess those employees identified training needs and develop a Comprehensive staff training plan for 2018 by December 1, 2017.

In addition, an evaluation of the 2017 Staff Training plan will be completed by December 1, 2017 and become part of the development of the 2018 Staff training plan.

Then by December 1, 2017 the assessment of the staff's training needs and the evaluation of the 2017 Staff training plan will be reviewed by the facility director and project directors with input from Compliance and Human Resources to develop a comprehensive Staff Training plan for the 2018 and years following using the same procedure.

It will be the Responsibility of Human Resources to monitor the timeline and to keep the Directors on task and ensure the Staff Training assessments, evaluation and plans are completed prior to the onset of the training year January - December


704.11(b)(1)  LICENSURE Individual training plan.

704.11. Staff development program. (b) Individual training plan. (1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
Observations
Nine personnel records were reviewed on March 29-30, 2017. The facility failed to document a complete individual training plan that included input from both the employee and the supervisor in personnel records # 1, 2, 3, 4, 5, 6, 7, 8, and 9. This finding was reviewed with facility staff during the licensing inspection.
 
Plan of Correction
Training plans will be completed for employees 1 through 9 with input from both the employee and supervisor by 5/31/2017.



To insure that this does not reoccur Human Resources will monitor that complete Training Plans for the individual employee includes input from both the employee and the supervisor and are documented in the personnel records per policy, procedure and regulation.

704.11(c)(1)  LICENSURE Mandatory Communicable Disease Training

704.11. Staff development program. (c) General training requirements. (1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
Observations
Eleven personnel records were reviewed on March 29, 2017 for the completion of required mandatory communicable disease training. The facility failed to document a minimum of 6 hours of HIV/AIDS training and a minimum of 4 hours of TB/STD training using a Department approved curriculum for employee records # 1, 2, 3, 5, and 8. This finding was reviewed with facility staff during the licensing inspection.
 
Plan of Correction
Employees 1, 2,3, 5, & 8 will remain in their current position.



They will be scheduled to attend the DDAP approved training for TB/STD/Hepatitis (6 hour) as well as the Basic HIV training to be completed by September 01, 2017.



All personnel records will be reviewed by Human Resources to see if any other employee is delinquent in this required training and schedule them accordingly before the end of training year, September 01, 2017.



To ensure that this does not occur again Human Resources will monitor, schedule new hires, as well as send out notifications and alerts to employees and supervisor when required trainings are due PRIOR to the expiration or due dates.

704.11(c)(2)  LICENSURE CPR CERTIFICATION

704.11. Staff development program. (c) General training requirements. (2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
Observations
Personnel records were reviewed for the completion of CPR certification training on March 29-30, 2017. The facility failed to ensure that at least one person certified in CPR skills was onsite during all hours of the facility's operation. Facility staff indicated that the facility's hours of operation are Monday - Saturday, 9 am - 9 pm. The facility failed to provide documenation that verified that at least one CPR certified staff person was onsite for the following hours of operation: Monday 5 pm - 9 pmTuesday 5 pm - 9 pmWednesday 3:30 pm - 9 pmThursday 3:30 pm - 9 pm Friday 5 pm - 9 pmSaturday 9 am - 9 pmThis finding was reviewed with facility staff during the licensing process.
 
Plan of Correction
On 4/11/2017 All Direct Client Care staff participated in CPR Certification. The completion of this training now insures that at least one person is certified in CPR skills is onsite during all hours of the facility's operation.



Going forward Human Resources will monitor all expiration dates of CPR and send out notices to employees that they need to be Re-Certified in CPR skills PRIOR to their expiration date.

704.11(d)(2)  LICENSURE Annual Training Requirements

704.11. Staff development program. (d) Training requirements for project directors and facility directors. (2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as: (i) Fiscal policy. (ii) Administration. (iii) Program planning. (iv) Quality assurance. (v) Grantsmanship. (vi) Program licensure. (vii) Personnel management. (viii) Confidentiality. (ix) Ethics. (x) Substance abuse trends. (xi) Developmental psychology. (xii) Interaction of addiction and mental illness. (xiii) Cultural awareness. (xiv) Sexual harassment. (xv) Relapse prevention. (xvi) Disease of addiction. (xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
Observations
One personnel record was reviewed for the facility director position on March 29, 2017. The facility failed to document the completion of at least 12 clock hours of training for employee record # 2. Employee # 2 was hired by the facility on 4/2015 as a facility director. The facility's training year is from January - December. Documentation in the employee's record indicated that the employee completed 7.5 training hours for the 2016 training year. This finding was reviewed with facility staff during the licensing process.
 
Plan of Correction
Employee #2 will remain in his current position.



He will be scheduled to complete the required 12 hours of training for the training year 2017.



Human Resources will be responsible for monitoring, scheduling and notifying staff that required training is due PRIOR to that due date.

704.11(g)(1)  LICENSURE Trng Req-Couns Asst

(g) Training requirements for counselor assistants. (1) Each counselor assistant shall complete at least 40 clock hours of training the first year and 30 clock hours annually thereafter in areas such as: (i) Pharmacology. (ii) Confidentiality. (iii) Client recordkeeping. (iv) Drug and alcohol assessment. (v) Basic counseling. (vi) Treatment planning. (vii) The disease of addiction. (viii) Principles of Alcoholics Anonymous and Narcotics Anonymous. (ix) Ethics. (x) Substance abuse trends. (xi) Interaction of addiction and mental illness. (xii) Cultural awareness. (xiii) Sexual harassment. (xiv) Developmental psychology. (xv) Relapse prevention. (h) Training hours. Training hours are not cumulative from one personnel classification to another.
Observations
Two personnel records were reviewed for the counselor assistant position on March 29-30, 2017. The facility failed to document the completion of 30 clock hours of annual training for employee record # 8. Employee # 8 was hired by the facility on 8/10/15 as a counselor assistant. The annual training year reviewed for this employee was 8/10/15 - 8/10/16. Documentation in the employee's record indicated that the employee completed 7.75 clock hours of annual training. This finding was reviewed with facility staff during the licensing inspection.
 
Plan of Correction
Employee #8 will remain in his current position.



Upon inquiry it was revealed that he had completed courses at Rutgers but was unable to obtain a transcript becuse he owed money. Human Resources will assist Employee to see if we can get some proof that he had taken classes and what Hours were accrued for Training Year August, 2015 - August, 2016.



The Facility Director and Clinical Supervisor are meeting with Employee #8 to determine the best training plan for current training year 2017 to obtain the required hours with the hope that it will him being able to enroll in school. If this is not possible we may need to consider other options. This will occur by 6/9/2017.



Human Resources will work with employee to meet his required hours for Training year 2017 by December 30, 2017.



To ensure that this does not occur again Human Resources will be responsible for monitoring and scheduling training as regulated and according to the staff's needs and facility training plan as well send out notifications PRIOR to due date.

705.10 (d) (4)  LICENSURE Fire safety.

705.10. Fire safety. (d) Fire drills. The residential facility shall: (4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
Observations
The facility's fire drill logs were reviewed on March 29, 2017, for the time period of March 2016 - February 2017. The facility failed to maintain a written fire drill record that included the exit route used during fire drills. This finding was reviewed with facility staff during the licensing inspection.
 
Plan of Correction
On March 30, 2017 the Director of Operations revised and updated the Fire Drill Logs to include date, time, the amount of time it took for evacuation, the exit route used, the number of person in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.



The following dates indicate that successful fire drills that were completed at each site after the inspection that included date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.



Yardley facility License# 097195

4/5/2017

5/2/2017

Bala Cynwyd facility License# 467132

4/28/2017

Fort Washington facility License# 467134

4/13/2017



The following dates are pending Fire Drills for May, 2017 that includes date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.



Bala Cynwyd facility License# 467132

5/18/2017

Fort Washington facility License# 467134

5/17/2017



To ensure that deficiency does not recur drills would be scheduled prior to the last day of the month. Then the facility director or designee will review all fire drill records to ensure that all areas were addressed. If any area was missing the facility director or designee would have another fire drill conducted so that all areas could be reviewed and documented.


709.26 (b) (3)  LICENSURE Personnel management.

709.26. Personnel management. (b) The personnel records must include, but are not limited to: (3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
Observations
Nine personnel records were reviewed on March 29-30, 2017. The facility failed to document an annual performance evaluation in employee record # 8. Employee # 8 was hired by the facility on 8/10/15 as a counselor assistant. An annual performance evaluation was not documented in the employee's record. This finding was reviewed with facility staff during the licensing inspection.
 
Plan of Correction
Employee #8 will remain in his current position.



His supervisor will complete an evaluation PRIOR to 6/1/2017 with follow up by 8/10/2017 to insure training hours are scheduled, that he is working towards being a counselor, and his performance is acceptable.



To ensure that this does not reoccur Human Resources will monitor, track, and notify supervisor when evaluations are due PRIOR to their due date.

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.
Observations
Ten client records were reviewed for the partial hospitalization and outpatient activities on March 30, 2017, for the licensing renewal inspection. The facility failed to obtain an informed and voluntary consent that documented the dated signature of a witness for client records # 1, 2, 4, 6, 7, 8, 9, and 10. The facility also failed to document the specific information to be disclosed and the purpose of the disclosure in client record # 5. In addition, the facility failed to document the date, event, or condition upon which the consent would expire for client records # 2, 3, 5, 8, and 9. Lastly, the facility facility exceeded the limitations imposed at 4 Pa. Code 255.5 (b) in client records # 1, 2, 3, 4, 6, 7, 8, 9, and 10. Client # 1 was admitted into partial hospitalization treatment at the facility on 2/10/17 and was transferred into outpatient treatment on 2/22/17. A consent to release information to an insurance company, the client's treatment funding source, did not document the dated signature of a witness. This consent form was signed and dated by the client on 12/8/16. In addition, the same consent form allowed for the release of the following: assessments, discharge/transfer summary, psychiatric evaluation, psychosocial evaluation, toxicology reports/drug screen, treatment plan or summary, nursing/medical assessment, and medication. Lastly, a consent to release information to the client's parent, signed and dated by the client on 12/8/16, did not document the dated signature of a witness. Documentation in the client's record indicates that facility contacted the parent by telephone on 2/14/17, with the client present. Client # 2 was admitted into partial hospitalization treatment at the facility on 3/15/17 and was still active in treatment. A consent to release information to an insurance company, the client's treatment funding source, did not document the dated signature of a witness and the date, event, or condition upon which the consent would expire. This consent form was signed and dated by the client on 3/15/17. In addition, the same consent form allowed for the release of the following: assessments, discharge/transfer summary, psychiatric evaluation, psychosocial evaluation, toxicology reports/drug screen, treatment plan or summary, nursing/medical assessment, and medication. Lastly, a consent to release information to the client's parent, signed and dated by the client on 3/16/17, did not document the dated signature of a witness. Documentation in the client's record indicated that the facility contacted the parent on 3/20/17, to provide an update on the client's progress in treatment. Client # 3 was transferred into partial hospitalization treatment at the facility on 12/14/16 and was discharged on 12/30/16. A consent to release information to an insurance company, the client's treatment funding source, did not document the dated signature of a witness and the date, event, or condition upon which the consent would expire. This consent form was signed and dated by the client on 8/30/16. In addition, the same consent form allowed for the release of the following: assessments, discharge/transfer summary, psychiatric evaluation, psychosocial evaluation, toxicology reports/drug screen, treatment plan or summary, nursing/medical assessment, and medication. Lastly, a consent to release information to the client's parent, signed and dated by the client on 8/30/16, did not document the dated signature of a witness and the date, event, or condition upon which the consent would expire. Documentation in the client's record indicated that the parent contacted the facility on 11/23/16 and was provided with information pertaining to the client's presence and progress in treatment. Client # 4 was admitted into partial hospitalization treatment at the facility on 9/20/16 and was discharged on 10/5/16. A consent to release information to an insurance company, the client's treatment funding source, did not document the dated signature of a witness. This consent form was signed and dated by the client on 9/20/16. In addition, the same consent form allowed for the release of the following: assessments, discharge/transfer summary, psychiatric evaluation, psychosocial evaluation, toxicology reports/drug screen, treatment plan or summary, nursing/medical assessment, and medication. Client # 5 was admitted into partial hospitalization treatment at the facility on 3/30/16 and was discharged on 4/15/16. A consent to release information to an insurance company, the client's treatment funding source, did not document the specific information to be disclosed, the purpose of the disclosure, and the date, event, or condition upon which the consent would expire. This consent form was signed and dated by the client on 3/25/16. In addition, a consent to release information to the client's parent, signed and dated on 3/26/16, did not document the dated signature of a witness. Documentation in the client's record indicated that the facility contacted the relative on 3/26/16, reporting the client's presence in treatment. Client # 6 was transferred into outpatient treatment at the facility on 7/21/16 and was still active in treatment. A consent to release information to an insurance company, the client's treatment funding source, did not document the dated signature of a witness. This consent form was signed and dated by the client on 6/6/16. In addition, the same consent form allowed for the release of the following: assessments, discharge/transfer summary, psychiatric evaluation, psychosocial evaluation, toxicology reports/drug screen, treatment plan or summary, nursing/medical assessment, and medication. Client # 7 was transferred into outpatient treatment at the facility on 2/22/17 and was still active in treatment. A consent to release information to an insurance company, the client's treatment funding source, did not document the dated signature of a witness. This consent form was signed and dated by the client on 12/8/16. In addition, the same consent form allowed for the release of the following: assessments, discharge/transfer summary, psychiatric evaluation, psychosocial evaluation, toxicology reports/drug screen, treatment plan or summary, nursing/medical assessment, and medication. Lastly, a consent to release information to the client's parent, signed and dated by the client on 12/8/16, did not document the dated signature of a witness. Information in the client's record indicated that the facility made phone contact with the parent on 2/14/17, with the client present. Client # 8 was admitted into outpatient treatment at the facility on 12/9/16 and was discharged on 1/16/17. A consent to release information to an insurance company, the client's treatment funding source, did not document the dated signature of a witness and the date, event, or condition upon which the consent would expire. This consent form was signed and dated by the client on 12/9/16. In addition, the same consent form allowed for the release of the following: assessments, discharge/transfer summary, psychiatric evaluation, psychosocial evaluation, toxicology reports/drug screen, treatment plan or summary, nursing/medical assessment, and medication. Client # 9 was transferred into outpatient treatment at the facility on 7/13/16 and was discharged on 8/8/16. A consent to release information to an insurance company, the client's treatment funding source, did not document the dated signature of a witness and the date, event, or condition upon which the consent would expire. This consent form was signed and dated by the client on 5/23/16. In addition, the same consent form allowed for the release of the following: assessments, discharge/transfer summary, psychiatric evaluation, psychosocial evaluation, toxicology reports/drug screen, treatment plan or summary, nursing/medical assessment, and medication. Lastly, a consent to release information to the client's parent, signed and dated by the client on 5/23/16, did not document the dated signature of a witness and the date, event, or condition upon which the consent would expire. Documentation in the client's record indicated that the facility contacted the parent on 7/21/16 and left a voicemail message. Additional documentation in the client's record indicated that the facility communicated with the parent on 7/26/16 and 8/8/16, and the parent was provided with information pertaining to the client's treatment and progress. Client # 10 was admitted into outpatient treatment at the facility on 1/19/17 and was discharged on 3/11/17. A consent to release information to the an insurance company, the client's treatment funding source, did not document the dated signature of a witness. This consent form was signed and dated by the client on 1/19/17. In addition, the same consent form allowed for the release of the following: assessments, discharge/transfer summary, psychiatric evaluation, psychosocial evaluation, toxicology reports/drug screen, treatment plan or summary, nursing/medical assessment, and medication. Lastly, a consent to release to the client's parent, signed and dated by the client on 1/19/17, did not document the dated signature of a witness. Documention in the client's record indicated that the facility contacted the parent to report the client's presence and progress in treatment on the following dates: 1/20/17, 2/1/17, 2/17/17, 3/2/17, and 3/11/17. These findings were reviewed with facility staff during the licensing inspection.
 
Plan of Correction
Generally, regarding the citation of those consents to release information that did not document the dated signature of a witness, due to a design issue with EMR system, it currently does not verify an actual dated witness signature. To resolve this matter until the designer of the EMR system addresses the issues all consents to release information cited will be printed out and the client and witness will sign and date each consent form. The consent forms will then be scanned back into the EMR. This will be accomplished by 6/15/2017.



Going forward effective immediately ALL consent forms until such time that the design of the Consents to Release Information is changed within the EMR, will be printed out and the client and a witness will sign and date each consent form. The consent forms will then be scanned back into the EMR. An expiration date will be clearly indicated.



Immediately going forward, no information that exceeds what is permissible to be released per 4 Pa. Code 255.5(b) will be released from any client records to those entities listed at 4 Pa. Code 255.5(b).



All records for currently active clients, including clients # 1-10 will be reviewed for any consent to release information forms that list items exceeding what is permitted to be released at 4 Pa. Code 255.5(b). All consents to release information that are out of compliance will be voided and new consent to release information forms will be completed. This will be completed by June 9, 2017.



To ensure that this does not recur, ALL Staff will be trained on the restrictions at 4 Pa. Code 255.5(b) and will be provided a print out to be kept at their desk by 6/9/2017.



The Clinical Supervisor will be responsible for reviewing all client records to ensure continued compliance.

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.
Observations
Five client records were reviewed for the partial hospitalization activity on March 30-31, 2017. The facility failed to completely document the type and frequency of treatment services on the individual treatment and rehabilitation plan for client records # 2 and 5. Client # 2 was admitted into partial hospitalization treatment at the facility on 3/15/17 and was still active in treatment. The client's individual treatment and rehabilitation plan, completed on 3/17/17, did not completely specify the type and frequency of counseling therapy. Client # 5 was admitted into partial hospitalization treatment at the facility on 3/30/16 and was discharged on 4/15/16. The client's individual treatment and rehabilitation plan, completed on 4/1/16, did not completely specify the type and frequency of counseling therapy. This finding was reviewed with facility staff during the licensing inspection.
 
Plan of Correction
CLient #2 Primary therapist will update the Type and Frequency in those objectives that have been left OPEN in this client plan of care by 5/19/2017.



Going forward all individual treatment and rehabilitation plan for the client record are part of Chart Audit done weekly. The type and frequency will be one of the variables monitored. All Objectives within the individual treatment and rehabilitation plan for the client records will have type and frequency identified.



The Clinical Supervisor is responsible for all supervision and correction of any deficiencies with the individual treatment and rehabilitation plan for the client record.

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.
Observations
Five client records were reviewed for the outpatient activity on March 30-31, 2017. The facility failed to document a treatment plan update at least every 60 days for client records # 6 and 9. Client # 6 was transferred into outpatient treatment at the facility on 7/21/16 and was still active in treatment. The last treatment plan update documented in the client's record was completed on 11/2/16. A subsequent treatment plan update was due to be completed for the client by 1/2/17. Additional treatment plan updates were not documented in the client's record. Client # 9 was transferred into outpatient treatment at the facility on 7/13/16 and was discharged on 8/8/16. The master treatment plan documented in the client's record was completed on 5/26/16. These findings were reviewed with facility staff during the licensing inspection.
 
Plan of Correction
Treatment Plan Updates will be completed for Client 6 & 9 by 5/19/2017.



All Outpatient client's clinical record will be monitored for completion of Treatment Plan Updates by 5/30/2017. Any client's Treatment Plan that has not been updated within 60 days will be updated. Supervision will be provided to the counselor.



Clinical Supervisor will be responsible for the ongoing monitoring of the client's Treatment Plan for updates to be done according to policy, procedure and regulations.

 
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