D&A Facility Surveys

Pennsylvania Department of Drug & Alcohol Programs
Inspection Results

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CENTER FOR FAMILIES
101 PHOENIXVILLE PIKE
MALVERN, PA 19355

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Survey conducted on 01/14/2021

INITIAL COMMENTS
Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, has implemented temporary procedures for conducting an annual renewal inspection. The inspection will be divided into two parts. 1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist. 2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection. This report is a result of Part 2, an abbreviated on-site inspection, conducted on January 5, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1. Based on the findings of Part 2, an abbreviated on-site inspection, Center for Families 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
705.28 (c) (4) LICENSURE Fire safety. 705.28. Fire safety. (c) Fire extinguishers. The nonresidential facility shall: (4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
Observations The facility failed to ensure that all staff were instructed in the use of fire extinguishers upon employment was documented in one of three applicable personnel records reviewed. Employee #2 was hired as a clinical supervisor on November 30, 2020. This finding was reviewed with facility staff during the licensing process.	Plan of Correction Execute Fire Safety Training/ Review with HR allocation of responsibilities for orientations process to ensure continuity. HR will review process that ensures that all employees are instructed as to how to properly use fire extinguisher. Director, completed this 2/2/21 with Clinical Supervisor (employee #2). Human resources is revising its methods to more accurately record fire safety training.
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.
Observations The facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in nine of nine client records reviewed. Client # 1 was admitted to the outpatient activity on July 15, 2020 and was discharged on August 21, 2020. There was a consent to release information form to the funding source, signed and dated by the client on July 16, 2020, that allowed for the release progress and treatment reports, school transcripts and records, medical history and physical, discharge planning and summary, psychosocial history, psychosocial evaluation, substance abuse treatment records, urine drug screen results, and financial, all of which exceeds 4 Pa. Code 255.5 (b). Client # 2 was admitted to the outpatient activity on October 30, 2019 and was discharged on December 20, 2019. There was a consent to release information form to the funding source, signed and dated by the client on October 30, 2019, that allowed for the release progress and treatment reports, school transcripts and records, medical history and physical, discharge planning and summary, psychosocial history, psychosocial evaluation, substance abuse treatment records, urine drug screen results, and financial, all of which exceeds 4 Pa. Code 255.5 (b). Client # 3 was admitted to the outpatient activity on May 7, 2020 and was discharged on July 24, 2020. There was a consent to release information form to the funding source, signed and dated by the client on March 9, 2020, that allowed for the release progress and treatment reports, school transcripts and records, medical history and physical, discharge planning and summary, psychosocial history, psychosocial evaluation, substance abuse treatment records, urine drug screen results, and financial, all of which exceeds 4 Pa. Code 255.5 (b). Client # 4 was admitted to the outpatient activity on February 10, 2020 and was discharged on February 24, 2020. There was a consent to release information form to the funding source, signed and dated by the client on January 13, 2020, that allowed for the release progress and treatment reports, school transcripts and records, medical history and physical, discharge planning and summary, psychosocial history, psychosocial evaluation, substance abuse treatment records, urine drug screen results, and financial, all of which exceeds 4 Pa. Code 255.5 (b). Client # 5 was admitted to the partial hospitalization activity on March 9, 2020 and was discharged on May 7, 2020. There was a consent to release information form to the funding source, signed and dated by the client on March 9, 2020, that allowed for the release progress and treatment reports, school transcripts and records, medical history and physical, discharge planning and summary, psychosocial history, psychosocial evaluation, substance abuse treatment records, urine drug screen results, and financial, all of which exceeds 4 Pa. Code 255.5 (b). Client # 6 was admitted to the partial hospitalization activity on January 13, 2020 and was discharged on February 10, 2020. There was a consent to release information form to the funding source, signed and dated by the client on January 13, 2020, that allowed for the release progress and treatment reports, school transcripts and records, medical history and physical, discharge planning and summary, psychosocial history, psychosocial evaluation, substance abuse treatment records, urine drug screen results, and financial, all of which exceeds 4 Pa. Code 255.5 (b). Client # 7 was admitted to the partial hospitalization activity on August 16, 2019 and was discharged on September 3, 2019. There was a consent to release information form to the funding source, signed and dated by the client on August 20, 2019, that allowed for the release progress and treatment reports, school transcripts and records, medical history and physical, discharge planning and summary, psychosocial history, psychosocial evaluation, substance abuse treatment records, urine drug screen results, and financial, all of which exceeds 4 Pa. Code 255.5 (b). Client # 8 was admitted to the partial hospitalization activity on June 17, 2019 and was discharged on July 5, 2019. There was a consent to release information form to the funding source, signed and dated by the client on June 17, 2019, that allowed for the release progress and treatment reports, school transcripts and records, medical history and physical, discharge planning and summary, psychosocial history, psychosocial evaluation, substance abuse treatment records, urine drug screen results, and financial, all of which exceeds 4 Pa. Code 255.5 (b). Client # 9 was admitted to the partial hospitalization activity on December 5, 2019 and was discharged on December 13, 2019. There was a consent to release information form to the funding source, signed and dated by the client on December 5, 2019, that allowed for the release progress and treatment reports, school transcripts and records, medical history and physical, discharge planning and summary, psychosocial history, psychosocial evaluation, substance abuse treatment records, urine drug screen results, and financial, all of which exceeds 4 Pa. Code 255.5 (b). This is a repeat citation from the June 17, 2019 licensing inspection. These findings were reviewed with facility staff during the licensing process.	Plan of Correction Head of Compliance to draft and solidify (*1) correct language in admissions paperwork. Work with Admissions department to ensure correct document is being distributed so that the consents and disclosure do not exceed Pa. Code 255.5 Head of Compliance to meet with Admissions to review distribution process and content, implement policy and procedure around CD client entry and protections
709.30 (1) 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. (1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
Observations The facility failed to document in writing that the clients were informed that all clients shall retain civil rights and liberties except as provided by statute and that no client may be deprived of a civil right solely by reason of treatment in nine of nine client records reviewed. Client # 1 was admitted to the outpatient activity on July 15, 2020 and was discharged on August 21, 2020. Client # 2 was admitted to the outpatient activity on October 30, 2019 and was discharged on December 20, 2019. Client # 3 was admitted to the outpatient activity on May 7, 2020 and was discharged on July 24, 2020. Client # 4 was admitted to the outpatient activity on February 10, 2020 and was discharged on February 24, 2020. Client # 5 was admitted to the partial hospitalization activity on March 9, 2020 and was discharged on May 7, 2020. Client # 6 was admitted to the partial hospitalization activity on January 13, 2020 and was discharged on February 10, 2020. Client # 7 was admitted to the partial hospitalization activity on August 16, 2019 and was discharged on September 3, 2019. Client # 8 was admitted to the partial hospitalization activity on June 17, 2019 and was discharged on July 5, 2019. Client # 9 was admitted to the partial hospitalization activity on December 5, 2019 and was discharged on December 13, 2019. These findings were reviewed with facility staff during the licensing process.	Plan of Correction Director will reiterate and emphasize this right to the clinical team both verbally and via email. Completed 2/2/21 via team meeting. Admissions overhaul will be inclusive of notices / Head of Compliance is currently reformulating all admissions packets and training dedicated site staff as to when and how to provide documentation of clients rights. This will be complete by 3/26/21
709.33 (b) LICENSURE Notification of termination. § 709.33. Notification of termination. (b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
Observations The facility failed to provide an involuntarily terminated client with an opportunity to request reconsideration of the facility's decision to terminate treatment in one of one applicable client records. Client #9 was admitted to the partial hospitalization activity on December 5, 2019 and was invluntarily discharged on December 13, 2019. There was no documentation on file indicating that the client was given an opportunity to request reconsideration of the discharge decision. This finding was reviewed with facility staff during the licensing process.	Plan of Correction The client shall have an opportunity to request reconsideration of a decision terminating treatment. Director will compete internal memo of these client protection and considerations. Training will be provided to clinical supervisor indicating steps that will need to be taken when a client is being terminated from treatment. Head of compliance will institute procedure whereby an outlined letter is drafted to have ready to provide client with rights and notification of opportunity to request reconsideration of discharge. All staff will be offered explanation and guidelines around said procedure and client right to reconsideration.
709.81(b)(6) LICENSURE Intake and admission 709.81. Intake and admission. (b) Intake procedures shall include documentation of: (6) Psychosocial evaluation.
Observations The facility failed to include documentation of a psychosocial evaluation during the intake and admission period in four of five client records reviewed. Client # 5 was admitted to the partial hospitalization activity on March 9, 2020 and was discharged on May 7, 2020. Client # 7 was admitted to the partial hospitalization activity on August 16, 2019 and was discharged on September 3, 2019. Client # 8 was admitted to the partial hospitalization activity on June 17, 2019 and was discharged on July 5, 2019. Client # 9 was admitted to the partial hospitalization activity on December 5, 2019 and was discharged on December 13, 2019. These findings were reviewed with facility staff during the licensing process.	Plan of Correction Missing BPS summary : Ongoing audits of BPS content as ensured by onsite compliance officer. Review of BPS process internally to ensure continuity of execution among therapists Internal audit via compliance officer Compliance officer shall report to Director of monthly audits and findings of completion as to ensure quality.