INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 20, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Casey 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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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.
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Observations
Based on a review of personnel records, the facility failed to provide adequate CPR certification to a sufficient number of staff persons, so that at least one person trained in CPR is onsite during the project's hours of operations.
At the time of the inspection, there was only one employee and they did not have a current CPR certification.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will schedule a CPR training session no later than 15 September 2023 for all staff members, including the Project Director, requiring certification or recertification. The Clinical Supervisor/lead counselor shall ensure that each weekly staff schedule reflects that at least one staff member is available during hours of operation. At the beginning of each calendar year, the Clinical Supervisor/lead counselor will review all staff training files to determine how many staff members require CPR qualification and will schedule a CPR training as needed. Full compliance will be achieved no later than 15 September 2023. |
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.
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Observations
Based on a review of the April 2022 through March 2023 fire drill logs, the facility failed to document, on the written fire drill logs, which the exit route was used and whether the fire alarm or smoke detector was operative for every fire drill conducted during the reviewed period.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director shall ensure that a written fire drill record is maintained and that it includes 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. The current fire drill log has been updated to include exit route used and whether the fire alarm or smoke detector was operative for every fire drill. The Clinical Supervisor/lead counselor will be responsible for reviewing the fire drill log and ensuring that all the information required by regulations. The Clinical Supervisor/lead counselor will also be responsible for the scheduling of fire drills, including a fire drill during sleeping hours at least every six months, preparing alternate routes, scheduling fire drills on different days of the week, and different times of the day, and determining whether to set off a fire alarm or smoke detector. The fire drill log will be securely stored in the Clinical Supervisor/lead counselor's office. The Project Director will review the fire drill log every three months to ensure compliance. |
709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
Based on an administrative review, the facility failed to document, and make available to the public, an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors, and principal shareholders.
This finding was discussed with facility staff during the licensing process.
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Plan of Correction
At the end of each calendar year the Project Director and key staff members will meet with the Governing Body to discuss the prior year's events and achievements. They will compile an annual report which includes, but is not limited to, a statement disclosing the names of officers, director, and principal shareholders. This report will be posted no later than 30 January of the upcoming year on the caseyrecovery.com website which is available to the public. The Clinical Supervisor/lead counselor will be responsible for posting the annual report. The Project director will provide oversight to ensure that the report is posted by 30 January of the upcoming year. |
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on an administrative review, the project failed to ensure that the project director annually updated and signed the written manual delineating the project's policies and procedures.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
At the end of each calendar year the governing body will meet with the Project Director and other staff members to review the previous calendar year's events and accomplishments. The facility's policy and procedure manual will be reviewed, updated and signed during this meeting. The Clinical Supervisor/lead counselor will consult with the Project Director one month prior to the annual meeting and will develop a checklist of items to be addressed during the annual meeting. Items on the checklist will include, but are not limited to, reviewing, updating and signing the facility policy and procedure manual. The Clinical Supervisor/lead counselor will be responsible for scheduling the annual meeting, and notifying the Project Director, governing body and other key staff members of the time and date of the annual meeting. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on an administrative review, the facility failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities. At the time of the inspection, there was no annual financial audit completed for the facility's fiscal year ending on December 31, 2021.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Casey Recovery's governing body has obtained the services of an independent certified public accountant. The Project Director will ensure annual financial audit for activities associated with the project's drug/alcohol abuse services will be available at the time of future inspections, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities. During the annual meeting with the governing body and other key staff members, which is conducted at the end of each calendar year, the Clinical Supervisor/lead counselor who will be responsible for scheduling the meeting and notifying key staff members of the time and date of the meeting, will also be responsible for setting the meeting agenda, which will include requesting the financial audit from the governing body for the previous calendar year. The audit for the fiscal year ending 12/31/21 has been completed as of this date. We are planning on requesting an exception because of our aborted opening last year we operated at a deficit, financially and we expect a similar situation when we re-open in the Fall of 2023.
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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 complete an informed and voluntary consent to release information form prior to the disclosure of information in two of ten applicable client records reviewed.
Client # 3 was admitted to the inpatient non-hospital detoxification activity on June 21, 2022 and was discharged on June 26, 2022. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
Client # 9 was admitted to the inpatient non-hospital activity on June 27, 2022 and was discharged on July 5, 2022. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will develop a written procedure which shall comply with 4 PA Code 255.5. which will include, but is not limited to, ensuring all client records must contain a consent release for information to any funding sources. The Clinical Supervisor/lead counselor will ensure that all clinical staff members receive DDAP approved training in confidentiality as well as in-house training in confidentiality documentation procedures. The Project Director will periodically review all clinical staff training files, providing oversight to ensure all staff members receive required trainings including confidentiality training. The Project Director will ensure a dedicated staff member is assigned to monitor quality assurance. This quality assurance staff member will be responsible for reviewing all closed client charts as well as continually monitoring open client charts to ensure compliance with all regulations including, but not limited to, confidentiality, as well as ensuring that all required consents are present in the client charts and are documented properly in accordance with Chapter 709.28(a,b,c,d,e). |
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 a review client records, the facility failed to document the purpose of the disclosure on release of information forms in one of ten applicable client records reviewed.
Client # 9 was admitted to the inpatient non-hospital activity on June 27, 2022 and was discharged on July 5, 2022. The release of information form to an emergency contact was completed on June 28, 2022, but the consent form did not include the purpose of the disclosure.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Project Director will develop a written procedure which shall comply with 4 PA Code 255.5 which will include, but is not limited to, 709.28(c)(3) Purpose of disclosure. The Clinical Supervisor/lead counselor will ensure that all clinical staff members receive DDAP approved training in confidentiality as well as in-house training in confidentiality documentation procedures. The Project Director will periodically review all clinical staff training files, providing oversight to ensure all staff members receive required trainings including confidentiality training. The Project Director will ensure a dedicated staff member is assigned to monitor quality assurance. this quality assurance staff member will be responsible for reviewing all closed client charts as well as continually monitoring open client charts to ensure compliance with all regulations including, but not limited to, confidentiality, as well as ensuring that all required consents are present in the client charts and are documented properly in accordance with Chapter 709.28(a,b,c,d,e.) |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document the dated signature of the client on release of information forms in ten of ten applicable client records reviewed.
In each client record reviewed, all the release of information forms had a typed client signature. The facility did not have full access to the electronic medical record to verify that the client was the one who electronically signed the release forms and there was no policy in place that detailed the validity of electronic signatures.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will develop a written procedure which will include, but is not limited to, 709.28(c)(4) Dated signature of client. The Clinical Supervisor/lead counselor will ensure that all clinical staff members receive DDAP approved training in confidentiality as well as in-house training in confidentiality documentation procedures. The Project Director will periodically review all clinical staff training files, providing oversight to ensure all staff members receive required trainings, including confidentiality trainings. The Project Director will ensure a dedicated staff member is assigned to monitor quality assurance. The quality assurance staff member will be responsible for reviewing all closed client charts as well as continually monitoring open client charts to ensure compliance with all regulations, including, but not limited to, confidentiality, as well as ensuring that all required consents are present in the client charts and are documented properly in accordance with Chapter 709.28(a,b,c,d,e.) Upon re-opening, Casey Recovery will be changing from electronic to hard copy (paper) charts and electronic signatures will not be an issue going forward. |
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 to release information form was offered to the client in four of ten client records reviewed.
Client # 4 was admitted to the inpatient non-hospital detoxification activity on June 22, 2022 and was discharged on June 26, 2022. The release of information forms to a funding source and a government agency were completed on June 22, 2022, but there was no documentation that a copy of either consent form was offered to the client.
Client # 5 was admitted to the inpatient non-hospital detoxification activity on June 28, 2022 and was discharged on July 5, 2022. The release of information forms to a funding source, a government agency and an emergency contact were completed on July 2, 2022, but there was no documentation that a copy of any of the consent to release information forms were offered to the client.
Client # 9 was admitted to the inpatient non-hospital activity on June 27, 2022 and was discharged on July 5, 2022. The release of information form to an emergency contact was completed on June 28, 2022, but there was no documentation that a copy of the consent to release information form was offered to the client.
Client # 10 was admitted to the inpatient non-hospital activity on June 27, 2022 and was discharged on June 30, 2022. The release of information forms to a funding source and a government agency were completed on June 22, 2022, but there was no documentation that a copy of any of the consent to release information forms were offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will develop a written procedure which shall comply with 4 PA Code 255.5 which will include, but is not limited to, Chapter 709.28(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record. The Clinical Supervisor/lead counselor will ensure that all clinical staff members receive DDAP approved training in confidentiality as well as in-house training in confidentiality documentation procedures. The Project Director will periodically review all clinical staff training files, providing oversight to ensure all staff members receive required trainings, including confidentiality training. The Project Director will ensure a dedicated staff member is assigned to monitor quality assurance. The quality assurance staff member will be responsible for reviewing all closed client charts as well as continually monitoring open client charts to ensure compliance with all regulations, including, but not limited to, confidentiality, as well as ensuring that all required consents are present in the client charts and are documented properly in accordance with Chapter 709.28(a,b,c,d,e.) |
709.29 (a) LICENSURE Retention of client records
§ 709.29. Retention of client records.
(a) Client records, regardless of format, shall be readily accessible for a minimum of 4 years following the discharge of a client.
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Observations
Based on a review of client records and conversations with facility staff, the facility failed to ensure that client records, regardless of the format, were readily accessible for a minimum of four years following the discharge of a client.
The facility has not had any active clients since July, 2022. At the time the clients were active, the facility had access to an electronic medical record software system. After the clients were discharged and the facility ceased admissions/operations, the facility ' s access to the electronic medical record system was terminated.
The facility had attempted to maintain printed copies of the electronic medical records; however, the printed client record copies for clients #10, #11, and #12 were incomplete and missing many required components of a complete client record.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Because of record retention issues we have experienced due to the use of electronic records, the facility's governing body and the Project Director have decided, upon re-opening, to use hard copy, paper, client charts. The Clinical Supervisor will be responsible for ensuring all clinical staff members are trained in facility documentation procedures beginning at their date of hire. The Project Director will provide oversight to ensure all staff are trained in facility documentation procedures. The Clinical Supervisor/lead counselor will ensure a dedicated clinical staff member is assigned to monitor quality assurance. The quality assurance staff member will review all closed client charts as well as continually monitoring open client charts to ensure compliance with facility documentation standards. The Clinical Supervisor/lead counselor will be responsible for ensuring that all closed charts are stored in a secure area on-site to ensure that they are available and easily retrievable for a minimum of four years following the discharge of any client. The Project Director will provide oversight and will visually inspect the record storage area every three months to ensure all client records are properly stored and retrievable. |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified that the project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client and that reasons for removing sections shall be documented in the record in ten of ten applicable client records reviewed.
In all ten applicable complete client records reviewed, the client handbook did not include notification of this specific regulatory client right and there was no other documentation indicating the client was notified of the client right.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor/lead counselor will develop policies and procedures regarding client rights and document written acknowledgement by clients that they have been notified of these rights, including, but not limited to, 709.30(3)"Clients have the right to inspect their own records. The project, facility, or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record." The Clinical Supervisor/lead counselor will ensure that all staff members receive in-house training regarding client rights as well as training in applicable documentation policies. The Project Director will provide oversight and will follow-up every three months to ensure that the policies and procedures have been developed and are being implemented. The client handbook will be edited to include Chapter 709.30 (1 thru 6.) |
709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right to appeal a decision limiting access to their records to the director in seven of seven client records reviewed.
In all ten applicable complete client record reviewed, the client handbook did not include notification of this regulatory client right and there was no other documentation indicating the client was notified of the client right.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor/lead counselor will develop policies and procedures regarding client rights and document written acknowledgement by clients that they have been notified of those rights, including, but not limited to, 709.30(4) "Clients have the right to appeal a decision limiting access to their records to the director."
The Clinical Supervisor will ensure that all staff members receive training in-house regarding client rights as well as training in applicable documentation policies. The Project Director will provide oversight and will follow-up every three months to ensure that the policies and procedures have been developed and are being implemented.
The client handbook will be edited to include Chapter 709.30 (1 thru 6) |
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 a review of client records and conversations with facility staff, the facility failed to develop a data collection and recordkeeping system that allows for the efficient retrieval of data needed to measure the project's performance in relationship to its stated goals and objectives as the facility was unable to maintain and retrieve the complete client records in four of twelve client records reviewed.
Client # 4 was admitted to the inpatient non-hospital detoxification activity on June 22, 2022 and was discharged on June 26, 2022. There was no medical chart, including medication records, doctor and nursing progress notes and a physical exam, documented in the client record.
Client # 10 was admitted to the inpatient non-hospital activity on June 27, 2022 and was discharged on June 30, 2022. There was no medical chart, including medication records, doctor and nursing progress notes and a physical exam, documented in the client record.
Client # 11 was admitted to the inpatient non-hospital activity on June 30, 2022 and was discharged on July 1, 2022. There were several documents missing from the client record including release of information forms, client orientation documents, treatment plans, progress notes and discharge documents. Additionally, there was no medical chart, including medication records, doctor and nursing progress notes and a physical exam, documented in the client record.
Client #12 was admitted to the inpatient non-hospital activity on July 2, 2022 and was discharged on July 4, 2022. There were several documents missing from the client record including release of information forms, client orientation documents, treatment plans, progress notes and discharge documents. Additionally, there was no medical chart, including medication records, doctor and nursing progress notes and a physical exam, documented in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Because of record retention problems regarding previous experience with electronic records the facility's governing body and the Project Director have decided that, upon re-opening, to use hard copy, paper, for all client charts, including medical charts. The Clinical Supervisor/lead counselor will be responsible for ensuring that all clinical staff members are trained in facility documentation procedures beginning at their date of hire. The Project Director will provide oversight to ensure all staff are trained or receiving training in facility documentation procedures. The Clinical Supervisor/lead counselor will assign a qualified clinical staff member to provide quality assurance services. The quality assurance staff member will provide reviews of all closed charts as well as ongoing reviews of open client charts. The Project Director will provide oversight. Periodically, every three months, the Project Director will meet with the Clinical supervisor/lead counselor, quality assurance staff, and other key staff members to ensure compliance with all facility documentation policies and procedures. |
709.34 (c) (3) 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:
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence that results in the closure of a facility for more than 1 day.
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Observations
Based on a review of the facility's March 2022 through April 2023 unusual incident logs and conversations with facility staff, the facility failed to file a written unusual incident report with the Department within 3 business days following a significant disruption of services due to a disaster such as fire, storm, flood, or other occurrence that results in the closure of the facility for more than 1 day.
The facility discharged all active clients and ceased operations as of July, 2022, due to stated staffing issues. The facility closure due to staffing issues was never reported to the Department within 3 business days.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Casey Recovery has DDAP approved policies and procedures regarding unusual incident reporting. Upon reopening, the Clinical Supervisor/lead counselor will be responsible for ensuring unusual incident reporting policies and procedures are complied with. The Clinical Supervisor will also be responsible for in-house training all staff regarding unusual incident reporting. The Project Director will provide oversight to ensure compliance. The Project Director will meet with the Clinical Supervisor/lead counselor as well as other key staff members to review the unusual incident file and review Chapter 709.34 including any updates and to ensure that any updates or changes are included in the unusual incident reporting policies and procedures. A hard copy of the unusual incident file will be securely stored in the Clinical Supervisor/lead counselor's office. |
709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document, during the intake process, a psychosocial evaluation in five of five applicable client records reviewed.
In each applicable inpatient non-hospital detoxification complete client record reviewed, there was no psychosocial evaluation documented at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will develop a written plan providing for intake and admission which includes, but is not limited to, 709.62(6) Psychosocial evaluation. The Clinical Supervisor/lead counselor will ensure that all staff members receive in-house training in facility intake and admission documentation policies and procedures. All staff trainings pertaining to intake and admission documentation will be documented and placed in the clinical staff members training file. The Project Director will periodically review, at a minimum, every three months, all staff training files to ensure compliance. The Project Director will assign a dedicated staff member as a quality assurance monitor. The quality assurance staff will review closed client charts as well as perform ongoing monitoring of open client charts to ensure compliance with regulations and facility documentation standards. This will include, but is not limited to, ensuring all client charts include a psychosocial evaluation. |
709.63(a)(2) LICENSURE D & A support plan
709.63. 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:
(2) Drug and alcohol support plan.
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Observations
Based on a review of client records, the facility failed to document a complete client record, which is to include a drug and alcohol support plan, in two of five applicable client records reviewed.
Client #1 was admitted to the inpatient non-hospital detoxification activity on June 14, 2022 and was discharged on June 21, 2022. The undated drug and alcohol support plan documented in the client record listed discharge information, including the discharge date and type of discharge, indicating that it was not developed until after the client was discharged from services.
Client #6 was admitted to the inpatient non-hospital detoxification activity on June 28, 2022 and was discharged on July 5, 2022. There was no drug and alcohol support plan documented in the client record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will review, update, and edit, if necessary, the project's existing policies and procedures regarding individual client records relative to the client's involvement with the project. In accordance with Chapter 709.63(a), including, but not limited to, drug and alcohol support plan. The Clinical Supervisor/lead counselor will ensure that all staff members receive in-house training in facility policies and procedures regarding client records as well as training in client record documentation policies. All staff trainings pertaining to client records will be documented and entered into the staff member's training file. The Project Director will review periodically, every three months, staff training files to ensure compliance. The Project Director will assign a dedicated staff member as a quality assurance monitor. The quality assurance staff member will review all closed charts as well as perform ongoing monitoring of open charts to ensure compliance with regulations and facility documentation standards. This will include, but is not limited to, ensuring that all client records include a drug and alcohol support plan. |
709.63(a)(8) LICENSURE Follow-up Information
709.63. 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) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document a complete client record, which is to include follow-up information, in four of seven applicable client records reviewed.
Client # 2 was admitted to the inpatient non-hospital detoxification activity on June 30, 2022 and was discharged on July 1, 2022. There was no documentation of follow-up information in the record at the time of the inspection.
Client # 5 was admitted to the inpatient non-hospital detoxification activity on June 22, 2022 and was discharged on June 23, 2022. There was no documentation of follow-up information in the record at the time of the inspection.
Client # 6 was admitted to the inpatient non-hospital detoxification activity on June 28, 2022 and was discharged on July 5, 2022. There was no documentation of follow-up information in the record at the time of the inspection.
Client # 7 was admitted to the inpatient non-hospital detoxification activity on June 28, 2022 and was discharged on July 5, 2022. There was no documentation of follow-up information in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will review, update and edit, if necessary, the project's existing policies and procedures regarding client records including, but not limited to, follow-up information. The Clinical Supervisor/lead counselor will ensure that all staff members receive in-house training on policies and procedures as well as facility documentation standards regarding client records. All staff trainings regarding client records will be documented and entered into the staff member's training file. The Project Director will periodically review, every three months, all staff training files to ensure compliance. The Project Director will assign a dedicated staff member as a quality assurance monitor. The quality assurance monitor will review closed client charts as well as perform ongoing reviews of open client charts to ensure compliance with regulations and facility documentation standards. This will include, but is not limited to, follow-up information. |
709.51(b)(1) LICENSURE Disclosure to client
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on a review of client records, the facility failed to document, during their intake process, the disclosure to the client of criteria for admission, treatment completion and discharge in one of three applicable client records reviewed.
Client # 9 was admitted to the inpatient non-hospital activity on June 27, 2022 and was discharged on July 5, 2022. There was no documentation of the disclosure to the client of the criteria for admission, treatment completion and discharge in the record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will develop a written plan providing for intake and admission which includes, but is not limited to, 709.51(1) Disclosure to the client of criteria for admission, treatment, completion and discharge. The Clinical Supervisor/lead counselor will ensure that all clinical staff members receive training in facility intake and admission policies and procedures. All trainings will be documented and placed in each staff member's training file. The Project Director will periodically, every three months, review staff training files to ensure compliance. The Project Director will assign a dedicated staff member to perform quality assurance duties. The quality assurance staff member will monitor charts to ensure compliance with all applicable regulations including, but not limited to, ensuring all client charts include documentation of disclosure to the client of criteria for admission, treatment, completion, and discharge. |
709.51(b)(2)(i) LICENSURE Client Orientation to Project
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(i) Project policies.
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Observations
Based on a review of client records, the facility failed to document, during the intake process, the client ' s orientation to the project in one of three applicable client records reviewed.
Client # 9 was admitted to the inpatient non-hospital activity on June 27, 2022 and was discharged on July 5, 2022. There was no documentation of client orientation to the project in the record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will develop a written plan providing for intake and admission which includes, but is not limited to, 709.51(b)(2) Client orientation to the project which includes, but is not limited to, project policies, hours of operation, fee schedule and services provided. The Clinical Supervisor/lead counselor will ensure that all clinical staff members receive training in facility intake and admission policies and procedures. all trainings will be documented and placed in each staff member's training file. The Project Director will periodically, every three months, review staff training files to ensure compliance. The Project Director will assign a dedicated staff member to perform quality assurance duties. The quality assurance staff member will monitor client charts to ensure compliance with all applicable regulations including, but not limited to, ensuring all client charts include documentation of the client's orientation to the project, which includes, but is not limited to, project policies, hours of operation, fee schedule and services provided. |
709.51(b)(4) LICENSURE Consent to treatment
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on a review of client records, the facility failed to document, during the intake process, a consent to treatment in one of three applicable client records reviewed.
Client # 9 was admitted to the inpatient non-hospital activity on June 27, 2022 and was discharged on July 5, 2022. There was no documentation of a consent to treatment in the record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will develop a written plan providing for intake and admission which includes, but is not limited to, 709.51(b)(4) Consent to treatment. The Clinical Supervisor/lead counselor will ensure that all clinical staff members receive training in facility intake and admission policies and procedures. All trainings will be documented and placed in each staff members training file. The Project Director will periodically, every three months, review staff training files to ensure compliance. The Project Director will assign a dedicated staff member to perform quality assurance duties. The quality assurance staff member will review all closed charts as well as perform ongoing reviews of open client charts to ensure compliance with all applicable regulations including, but not limited to, ensuring a completed consent to treatment document which will be signed and dated by both the client and staff member. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document, during the intake process, a psychosocial evaluation in two of two applicable client records reviewed.
Client # 8 was admitted to the inpatient non-hospital activity on June 22, 2022 and was discharged on July 5, 2022. The client record did not document a psychosocial evaluation at the time of the inspection.
Client # 9 was admitted to the inpatient non-hospital activity on June 27, 2022 and was discharged on July 5, 2022. The client record did not document a psychosocial evaluation at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will develop a written plan providing for intake and admission which includes, but is not limited to, Chapter 709.51(b)(6) Psychosocial evaluation. The Clinical Supervisor/lead counselor will ensure that all clinical staff members receive training in facility intake and admission policies and procedures as well as facility documentation policies and procedures. All trainings will be documented and placed in each staff member's training file. The Project Director will periodically, every three months, review staff training files to ensure compliance. The Project Director will assign a dedicated staff member to perform quality assurance duties. The quality assurance staff member will review all closed client charts as well as perform ongoing reviews of open client charts to ensure compliance with all applicable regulations including, but not limited to, ensuring a completed psychosocial evaluation is documented in all client charts. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. 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 during their treatment at the facility in one of two applicable client records reviewed.
Client # 8 was admitted to the inpatient non-hospital activity on June 22, 2022 and was discharged on July 5, 2022. The undated individual treatment plan documented in the client record listed discharge information, including the discharge date and type of discharge, indicating that it was not developed until after the client was discharged from services.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will review, update, and edit, if necessary, the project's existing policies and procedures regarding Chapter 709.52 Treatment and rehabilitative services. The Clinical Supervisor/lead counselor will ensure that all staff members receive in-house training in facility policies and procedures regarding treatment planning as well as training in facility client record documentation policies. All staff trainings pertaining to treatment planning will be documented and entered into each staff member's training file. The Project Director will periodically review, every three months, staff training files to ensure compliance. The Project Director will assign a dedicated staff member as a quality assurance monitor. The quality assurance staff member will review all closed client charts as well as perform ongoing reviews of open charts to ensure compliance with regulations and facility documentation standards. This will include, but is not limited to, ensuring that all client records include an individual treatment and rehabilitation plan. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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 a review of client records, the facility failed to document a complete client record, which is to include follow-up information, in two of three applicable client records reviewed.
Client # 8 was admitted to the inpatient non-hospital activity on June 22, 2022 and was discharged on July 5, 2022. There was no documentation of a follow-up being completed as of the date of the inspection.
Client # 9 was admitted to the inpatient non-hospital activity on June 27, 2022 and was discharged on July 5, 2022. There was no documentation of a follow-up being completed as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will review, update, and edit, if necessary, the project's existing policies regarding Chapter 709.53 Client records including, but not limited to, 709.53(a)(11) Follow-up information. The Clinical Supervisor/lead counselor will ensure that all staff members receive in-house training in facility policies and procedures regarding client records as well as training in facility documentation policies. All staff trainings regarding client records will be documented and entered into each staff member's training file. The Project Director will assign a dedicated staff member as a quality assurance monitor. The quality assurance staff member will review all closed client charts as well as perform ongoing reviews of open client charts to ensure compliance with all regulations and facility documentation standards. This will include, but is not limited to, ensuring that all client charts include follow-up information. |