INITIAL COMMENTS
|
Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, 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 September 16, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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, Open Door Counseling at Mazzoni Center 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
|
709.28 (c) (5) 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:
(5) Dated signature of witness.
|
Observations
Based on a review of client records, the project failed to document the dated witness signature on an informed and voluntary consent to release information form signed by the client in one of seven records reviewed.
Client #2 was admitted on January 15, 2020 and was a current client at the time of the inspection. This client's record contained three consent to release information forms, all signed by the client on January 15, 2020; one for a primary care physician, one for the funding source and one for a family member. All three consent to release information forms did not have a dated witness signature.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Director reviewed the finding and addressed this issue with the staff responsible. We reviewed the standard protocol for completing consent forms, including witnessing with signature and date. Assistant Director will monitor for ongoing compliance during regular chart audits. Director will ensure regular chart auditing occurs. |
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
Based on a review of client records, the facility failed to ensure that treatment and rehabilitation plans were reviewed and updated at least every 60 days in three of seven client records reviewed.
Client #1 was admitted on February 27, 2020 and was a current client at the time of the inspection. A treatment plan update was completed on April 2, 2020 and the next update was due no later than June 2, 2020; however, the next documented treatment plan update was dated for July 15, 2020.
Client #2 was admitted on January 15, 2020 and was a current client at the time of the inspection. A comprehensive treatment plan was documented in the record for February 26, 2020 and the update was due no later than April 26, 2020; however, the next documented treatment plan update was dated for July 9, 2020. Additionally, the next treatment plan update was due not later than September 9, 2020; however, the treatment plan update was not documented in the records at the time of the inspection.
Client #6 was admitted on July 16, 2019 and was discharged on February 7, 2020. A treatment plan update was completed on October 24, 2019 and the next update was due no later than December 24, 2019; however, the next documented treatment plan update was dated for January 30, 2020.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Director reviewed the finding. The timeframes for completion of treatment plans was reviewed with staff. We discussed expected timeframes and troubleshot potential obstacles. Staff are aware of expectations and ways to workaround potential challenges that may arise in completing Treatment Plans within expected timeframes. Clinical Supervisor will monitor progress through regular chart reviews and Assistant Director will oversee through routine random chart audits. Director will monitor compliance on an ongoing basis. |