INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 21, 2021 and January 29, 2021 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) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the project failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in one of fourteen client records reviewed.Client #10 was admitted on September 21, 2020 and was discharged on October 14, 2020. A release of information form to a funding source signed and dated by the client on September 21, 2020, allowed for the release of recovery plans, discharge/continuing care planning, screening tools, encounter details, miscellaneous note details and TAP assessment, all of which exceeds the limits established by 4 Pa. Code 255.5.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During Treatment Team Meeting held on March 1, 2021, President & CEO educated all counselors regarding the information that is permissible to be released to SCA (funding source) established by 4 Pa. Code 255.5. President & CEO reviewed the following information as permissible to release to SCA per the WITS consents: Admission, Client Profile, Consent, Diagnosis List, Discharge & Intake Transaction. The counselors were each provided with handouts outlining the above information to release per WITS consents. President & CEO & the Case Management Coordinator will conduct internal chart reviews throughout the year 2021 to ensure compliance is maintained. The agency will be in full compliance with this standard effective 3/1/21. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on the review of client records, the project failed to document two weekly individual counseling sessions in four of four partial hospitalization clients reviewed.Client #4 was admitted on March 5, 2020 and was discharged on July 31, 2020. Prior to stepping down to outpatient services on May 8, 2020, the project failed to document two of the two individual counseling sessions required weekly for the weeks of March 14, 2020 through March 20, 2020 and April 4, 2020 through April 10, 2020. The project failed to document one of the two individual counseling sessions required weekly for the weeks of March 7, 2020 through March 12, 2020, March 28, 2020 through April 4, 2020 and April 25, 2020 through May 1, 2020.Client #6 was admitted on August 7, 2020 and was a current client at the time of the inspection. Prior to stepping down to outpatient services on December 30, 2020, the project failed to document two of the two individual counseling sessions required weekly for the weeks of September 20, 2020 through September 26, 2020, November 8, 2020 through November 14, 2020, November 15, 2020 through November 21, 2020, November 22, 2020 through November 28, 2020 November 29, 2020 through December 5, 2020 and December 6, 2020 through December 12, 2020. The project failed to document one of the two individual counseling sessions required weekly for the weeks of August 9, 2020 through August 15, 2020, August 16, 2020 through August 22, 2020, August 30, 2020 through September 5, 2020 and September 27, 2020 through October 3, 2020.Client #10 was admitted on September 21, 2020 and was discharged on October 14, 2020. The project failed to document one of the two individual counseling sessions required weekly for the week of September 27, 2020 through October 3, 2020. Client #12 was admitted on August 3, 2020 and was September 18, 2020. The project failed to document two of the two individual counseling sessions required weekly for the weeks of August 9, 2020 through August 15, 2020, August 23, 2020 through August 29, 2020, August 30, 2020 through September 5, 2020 and September 6, 2020 through September 12, 2020. The project failed to document one of the two individual counseling sessions required weekly for the week of August 3, 2020 through August 8, 2020.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During Treatment Team Meeting held on March 1, 2021, President & CEO educated all counselors regarding the PHP requirements of Individual Counseling Sessions occurring twice weekly. Counselors will notify the front desk staff of any clients needing recurring Individual Sessions twice weekly; these sessions will be incorporated into the counselors' schedule on recurring basis. Counselors will document the Individual Counseling Sessions in the client's chart in Record of Service. If the agency must cancel or reschedule an Individual Counseling session, an additional session will be scheduled within that same week of service, calendar permitting. Any client cancellations, rescheduling or failure to attend will be documented by the counselors in the clients' chart in Record of Service. All engagement efforts with clients for PHP Individual Counseling attendance will be documented in Case Notes. President & CEO & Case Management Coordinator will conduct internal chart reviews of all PHP clients throughout the year 2021. Additionally, meetings will occur with counselors, as needed, to address any noncompliance issues. The agency will be in full compliance with this standard effective 3/31/21. |
709.82(d)(2) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(2) Group counseling, at least twice weekly.
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Observations
Based on the review of client records, the project failed to document two weekly group counseling sessions in two of four partial hospitalization clients reviewed.Client #10 was admitted on September 21, 2020 and was discharged on October 14, 2020. The project failed to document two of the two group counseling sessions required weekly for the weeks of September 21, 2020 through September 26, 2020 and September 27, 2020 through October 3, 2020. Client #12 was admitted on August 3, 2020 and was September 18, 2020. The project failed to document two of the two group counseling sessions required weekly for the weeks of August 3, 2020 through August 8, 2020, August 9, 2020 through August 14, 2020, August 16, 2020 through August 22, 2020, August 23, 2020 through August 29, 2020, August 30, 2020 through September 5, 2020 and September 6, 2020 through September 12, 2020. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During Treatment Team Meeting held on March 1, 2021, President & CEO educated all counselors regarding the PHP requirements of Group Counseling Sessions occurring twice weekly. Counselors will document the Group Sessions in the client's chart in Record of Service. If the agency must cancel or reschedule one of the two Group Sessions, an additional Group Session will be scheduled that same week of service, calendar permitting. Any client cancellations, rescheduling or failure to attend will be documented by the counselors in the client's chart in Record of Service. All engagements efforts with clients for PHP Group Session attendance will be documented in Case Notes. President & CEO & Case Management Coordinator will conduct internal chart reviews of all PHP clients throughout the year 2021 to ensure compliance is maintained. The President & CEO and/or the Case Management Coordinator will schedule additional meetings with counselor(s), as needed, to address any noncompliance issues. The agency will be in full compliance with this standard effective 3/31/21. |