INITIAL COMMENTS
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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 April 28 - 29, 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, Clear Choices 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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715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on a review of patient records, the facility failed to document an annual evaluation of each patient's status in one of three patient records reviewed on April 28 - 29, 2021.
Patient # 7 was admitted May 23, 2018 and discharged April 26, 2021. There was no documentation of an annual evaluation for 2020.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will provide in-house training related to Annual Clinical Evaluation content and completion to the Clinical Staff on May 25, 2021. Facility Director will document the training via issuance of training certificates to staff and will maintain documentation of the training on site for review. Clinical Supervisor will monitor on-going compliance through random chart audits to ensure compliance. |
709.93(a)(8) LICENSURE Client records
709.93. 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) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document case consultation notes, per facility policy, in five of ten client records reviewed on April 28 - 29, 2021.
The facility's policy requires case consultations quarterly and then annually after one year in treatment.
Client # 2 was admitted December 28, 2020. No case consultations were documented.
Client # 3 was admitted July 6, 2020. The only case consultations documented were October 5, 2020 and December 16, 2020.
Client # 6 was admitted October 30, 2019 and discharged June 2, 2020. No case consultations were documented.
Client # 7 was admitted May 23, 2018 and discharged April 26, 2021. No annual case consultation was documented for 2020.
Client # 9 was admitted February 3, 2020. The only case consultations documented were May 6, 2020 and August 4, 2020.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will provide in-house training related to Case Consultations including both quarterly and annual content and completion to the Clinical Staff on May 25, 2021. Facility Director will document the training via issuance of training certificates to staff and will maintain documentation of the training on site for review. Clinical Supervisor will monitor on-going compliance through random chart audits to ensure compliance. |