INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up inspection and complaint investigation conducted on August 3, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Clearvision Health and Wellness - Hazelton 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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704.9(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.
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Observations
Based on a review of one applicable counselor assistant ' s personnel record, the facility failed to ensure that a counselor assistant with a bachelor ' s degree was counseling clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
Close supervision is defined by regulation as follows: " Formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week " .
Employee #1 was hired as a counselor assistant on July 18, 2022 and was current in that position at the time of inspection. The facility ' s documented weekly supervision dated July 22, 2022 and July 28, 2022 did not include a formal documented case review nor was there reference to the hour of direct observation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will correct this deficiency by changing the current supervision document being used to include a formal documented case review and an additional hour of direct observation by a Clinical Supervisor once a week.
The Clinical Supervisor will schedule a training on counselor assistant supervision to ensure appropriate counseling and documentation is taking place.
The Clinical Supervisor will monitor counselor assistant supervision notes by having a case consult that is documented in the weekly supervision notes and is also reflected in the client's chart.
The Clinical Supervisor will provide direct observation and have a weekly log completed to support this.
The Assistant Executive Director will be responsible and monitor the above action is being done to avoid this from recurrence.
The corrective action will be completed by August 22, 2022. |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of seven client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the name of the person, agency or organization to whom disclosure is made, in one record reviewed.
Client #2 was admitted on July 7, 2022 and was current at the time of the inspection. Client #2 had an informed and voluntary consent signed by the client and dated July 7, 2022, that did not include the name of the person, agency or organization to whom the disclosure could be made.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the February 10, 2022 licensing inspection.
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Plan of Correction
This facility will correct this deficiency by ensuring all consents for each client are filled out in their entirety and include the name of the person, agency or organization to whom the disclosure could be made.
The client was current at the time of inspection and this blank consent form was removed from the chart on 08/04/2022.
The Assistant Executive Director will monitor charts daily and ensure no blank consent forms exist. The Assistant Executive Director will also check the consent forms that are generated in a client's chart, and ensure the name of the person, agency or organization is documented with all of the correct information. This will be monitored daily. The Assistant Executive Director will ensure the corrective action plan is implemented.
The corrective action plan will be completed immediately - 08/19/2022. |
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 of seven client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the purpose of disclosure, in one record reviewed.
Client #2 was admitted on July 7, 2022 and was current at the time of the inspection. Client #2 had an informed and voluntary consent signed by the client and dated July 7, 2022, that did not include the purpose of disclosure.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the February 10, 2022 licensing inspection.
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Plan of Correction
This facility has corrected this deficiency by removing the signed release that was blank from the client's chart on the electronic medical record.
The client has been discharged from the facility since the inspection.
The facility will correct this deficiency by removing any blank releases from the client's chart and generating a new release that has all of the necessary information documented as well as the purpose of disclosure of filled out completely.
The Assistant Executive Director will be responsible for ensuring the corrective action is implemented and the deficiency does not recur by doing daily chart checks.
The Facility Executive Director will monitor charts weekly by going through each client's consent forms.
The corrective action plan will take place immediately - 08/19/2022. |
709.30 (2) 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.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of seven client records, the project failed to document written acknowledgement by clients that they have been notified of their right not to be discriminated in the provision of services on the basis of ethnicity, marital status, sexual orientation, handicap or religion in all ten records reviewed.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the February 10, 2022 licensing inspection.
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Plan of Correction
This facility will correct the client rights form in the electronic medical record. This form will be written acknowledgement and will be signed by each client that will notify them they are not to be discriminated against in the provision of services on the basis of ethnicity, marital status, sexual orientation, handicap or religion.
The Assistant Executive Director will be responsible for this corrective action and ensure this deficiency does not recur.
The correction action plan will be completed by 08/22/2022.
The corrective action date will be 08/22/2022. |
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 seven client records, the project failed to document written acknowledgement by clients, in all records reviewed, that they have been notified of their 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.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the February 10, 2022 licensing inspection.
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Plan of Correction
This facility will correct this by changing the client rights form on the electronic medical record that each client will sign and serve as written acknowledgement that they have been notified of their 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 Assistant Executive Director will be responsible for ensuring the correction plan is implemented and does not recur.
The corrective action plan will be completed on 08/22/2022. |
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 seven client records, the project failed to document written acknowledgement by clients, in all records reviewed, that they have been notified of their right to inspect their own records, and they have the right to appeal a decision limiting access to their records to the director.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the February 10, 2022 licensing inspection.
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Plan of Correction
This facility will correct this deficiency by amending the client rights form in the electronic medical record to keep written acknowledgement by clients that they they have been notified of their right to inspect their own records, and they have the right to appeal a decision limiting access to their records to the director.
The Assistant Executive Director will be responsible for ensuring the corrective action is implemented and does not recur.
The corrective action plan will be completed on 08/22/2022. |
709.30 (5) 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.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Based on a review of seven client records, the project failed to document written acknowledgement by clients, in all records reviewed, that they have been notified of their right to inspect their own records, and that they have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the February 10, 2022 licensing inspection.
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Plan of Correction
This facility will correct this deficiency by amending the client rights form in the electronic medical record that will serve as written acknowledgement by clients that they have been notified of their right to inspect their own records, and that they have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
The Assistant Executive Director will be responsible for ensuring the corrective action is implemented and does not recur.
The corrective action plan will be completed on 08/22/2022. |
709.30 (6) 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.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on a review of seven client records, the project failed to document written acknowledgement by clients, in all records reviewed, that they have been notified of their right to inspect their own records, and that they have the right to submit rebuttal data or memoranda to their own records.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the February 10, 2022 licensing inspection.
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Plan of Correction
This facility will correct the client rights form in the electronic medical record. This form will be written acknowledgement and will be signed by each client that will notify them they have been notified of their right to inspect their own records, and that they have the right to submit rebuttal data or memoranda to their own records.
The Assistant Executive Director will be responsible for ensuring the corrective action is implemented and the deficiency does not recur.
The corrective action plan will be completed by 08/22/2022. |
709.52(a)(3) LICENSURE Support service type
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:
(3) Proposed type of support service.
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Observations
Based on a review of seven client records, the facility failed to include proposed type of support services on the individual treatment and rehabilitation plans developed with the clients in five records reviewed.
Client #3 was admitted on July 25, 2022 and was current at the time of the inspection. An individual treatment and rehabilitation plan developed with the client on July 27, 2022 did not include any proposed type of support services.
Client #4 was admitted on Jube 2, 2022 and discharged on June 7, 2022. An individual treatment and rehabilitation plan developed with the client on June 3, 2022 did not include any proposed type of support services.
Client #5 was admitted on May 20, 2022 and discharged June 2, 2022. An individual treatment and rehabilitation plan developed with the client on May 21, 2022 did not include any proposed type of support services.
Client #6 was admitted on May 21, 2022 and discharged on June 17, 2022. An individual treatment and rehabilitation plan developed with the client on May 23, 2022 did not include any proposed type of support services.
Client #7 was admitted on March 10, 2022 and discharged on April 19, 2022. An individual treatment and rehabilitation plan developed with the client on March 11, 2022 did not include any proposed type of support services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This facility will correct this deficiency by adding proposed type of support services on the individual treatment and rehabilitation plans that are developed with the clients.
Client's 3-7, all whom have been discharged since the inspection and charts are closed, did not have proposed type of support services on their individual treatment plans.
The initial treatment plan/comprehensive treatment plan on the electronic medical record will be amended to include a section that has type of support services.
The Assistant Executive Director will make sure support services is included on each client's comprehensive treatment plan by doing daily chart checks.
The Assistant Executive Director will be responsible for ensuring the corrective action is implemented and this deficiency does not recur.
The Facility Executive Director will monitor this by doing weekly checks of each client's chart, ensuring support services is added to the comprehensive treatment plan.
The corrective plan of action will be completed by 08/22/2022. |