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 22, 2021 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, Little Creek Outpatient Services, 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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709.28 (c) 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.
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Observations
Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in four of fourteen client records reviewed.
Client #1 was admitted on February 3, 2020 and was discharged on March 2, 2020. A release of information form for the funding source was not documented in the client record.
Client #5 was admitted on March 18, 2021 and was discharged on April 16, 2021. A release of information form for the funding source was not documented in the client record.
Client #8 was admitted on December 3, 2019 and was discharged on July 27, 2020. A release of information form for the funding source was not documented in the client record.
Client #12 was admitted on August 20, 2020 and was an active client at the time of the inspection. A release of information form for the funding source was not documented in the client record.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Clinical Director conducted an in-person Clinical Team meeting on 5/6/21. The program's confidentiality policy and associated commonwealth law 4 Pa Code 255.5 what distributed to each member and reviewed. The law and parameters around release of information to funding sources was discussed. Additionally, a blank 255.5 ROI was added to the client admission packet on 5/5/21. This was showed to the clinical team members in the meeting on 5/6/21 and they will now be completed with the client immediately upon admission with the other admission paperwork. These ROI's only contain the 5 items permitted to be released to these entities with the client's signed consent. Clinical Director will audit all completed admission paperwork for clients for the next 4 months, or until these forms are being properly completed 100% of the time over a 2 week period. |
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 six of fourteen client records reviewed.
Client #3 was admitted on December 30, 2020 and was discharged on March 9, 2021. A release of information form to a probation agency, signed and dated by the client on December 30, 2020, allowed for the release of progress notes, treatment plans, BPS assessments, medical history/current status, discharge/transfer planning, discharge summary/aftercare recommendations, medical progress notes and assessments, urine analysis results, laboratory test results, psychiatric history and assessment evaluation, family information, legal status and employment information, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #4 was admitted on January 19, 2021 and was discharged on March 18, 2021. Three release of information forms, one to a probation agency and two to family members, signed and dated by the client on January 17, 2021, did not document the specific information to be disclosed.
Client #8 was admitted on December 3, 2019 and was discharged on July 27, 2020. A release of information form to a child welfare agency, signed and dated by the client on December 3, 2020, allowed for the release of urine analysis results and family information, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #9 was admitted on March 11, 2020 and was discharged on November 13, 2020. A release of information form to a probation agency, signed and dated by the client on May 20, 2020, allowed for the release of discharge summary/aftercare recommendations, urine analysis results, laboratory test results and legal status, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #10 was admitted on June 10, 2020 and was discharged on December 18, 2020. A release of information form to a probation agency, signed and dated by the client on June 10, 2020, allowed for the release of discharge summary/aftercare recommendations, urine analysis results, laboratory test results and legal status, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #13 was admitted on October 6, 2020 and was a current client at the time of the inspection. A release of information form to a probation agency, signed and dated by the client on October 10, 2020, allowed for the release of discharge summary/aftercare recommendations, urine analysis results, laboratory test results and legal status, all of which exceeds the limits established by 4 Pa. Code 255.5.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Clinical Director conducted an in-person Clinical Team meeting on 5/6/21. The program's confidentiality policy and associated commonwealth law 4 Pa Code 255.5 what distributed to each member and reviewed. Laws around release of information to funding sources and legal entities were discussed. Additionally, a blank 255.5 ROI was added to the client admission packet on 5/5/21. This was showed to the clinical team members in the meeting on 5/6/21 and they will now be completed with the client immediately upon admission with the other admission paperwork. These ROI's only contain the 5 items permitted to be released to these entities with the client's signed consent. Clinical Director will audit all completed admission paperwork for clients for the next 4 months, or until these forms are being properly completed 100% of the time over a 2 week period. |
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 provide individual counseling at least twice a week in six of seven applicable client records reviewed.
Client #1 was admitted on February 3, 2020 and was discharged on March 2, 2020. There was no documentation in the client record confirming that the client received one of the two required individual counseling session for the weeks of February 5, 2020 through February 11, 2020, February 12, 2020 through February 18, 2020, February 19, 2020 through February 25, 2020 and February 26, 2020 through March 1, 2020.
Client #2 was admitted on September 9, 2020 and was discharged on October 5, 2020. There was no documentation in the client record confirming that the client received two of the two required individual counseling sessions for the week of September 13, 2020 through September 19, 2020 and one of the two required individual counseling sessions for the weeks of September 20, 2020 through September 26, 2020 and September 27, 2020 through October 3, 2020.
Client #4 was admitted on January 19, 2021 and was discharged on March 18, 2021. There was no documentation in the client record confirming that the client received two of the two required individual counseling sessions for the weeks of January 31, 2021 through February 6, 2021 and February 28, 2021 through March 6, 2021 and one of the two required individual counseling sessions for the weeks of January 24, 2021 through January 30, 2021, February 7, 2021 through February 13, 2021 and February 21, 2021 through February 27, 2021.
Client #5 was admitted on March 18, 2021 and was discharged on April 16, 2021. There was no documentation in the client record confirming that the client received two of the two required individual counseling sessions for the weeks of March 21, 2021 through March 27, 2021 and March 28, 2021 through April 3, 2021 and one of the two required individual counseling sessions for the week of April 4, 2021 through April 10, 2021.
Client #6 was admitted on March 29, 2021 and was a current client at the time of the inspection. There was no documentation in the client record confirming that the client received one of the two required individual counseling session for the week of April 4, 2021 through April 10, 2021.
Client #7 was admitted on April 6, 2021 and was a current client at the time of the inspection. There was no documentation in the client record confirming that the client received two of the two required individual counseling session for the weeks of April 6, 2021 through April 22, 2021.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
In a clinical team meeting on 5/6/21, Clinical Director printed out and disseminated program policies and procedures. The type and frequency of services (groups and individual sessions) was reviewed and the rationale behind the type and frequency were explained. Clinical Director will review Clinician's weekly schedules beginning on 5/6/21 and moving forward, to ensure all PHP clients are being scheduled and seen for 2 30-minute individual counseling sessions per week. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on the review of client records, the project failed to document an individual treatment and rehabilitation plan that included the type and frequency of the treatment and rehabilitation services in seven of seven applicable client records reviewed.
Client #8 was admitted on December 3, 2019 and was discharged on July 27, 2020. A comprehensive treatment and rehabilitation plan, documented on December 3, 2020, did not include the type and frequency of the rehabilitation services to be provided to the client.
Client #9 was admitted on March 11, 2020 and was discharged on November 13, 2020. A comprehensive treatment and rehabilitation plan, documented on March 11, 2020, did not include the type and frequency of the rehabilitation services to be provided to the client.
Client #10 was admitted on June 10, 2020 and was discharged on December 18, 2020. A comprehensive treatment and rehabilitation plan, documented on June 10, 2020, did not include the type and frequency of the rehabilitation services to be provided to the client.
Client #11 was admitted on September 15, 2020 and was discharged on December 18, 2020. A comprehensive treatment and rehabilitation plan, documented on September 15, 2020, did not include the type and frequency of the rehabilitation services to be provided to the client.
Client #12 was admitted on August 20, 2020 and was an active client at the time of the inspection. A comprehensive treatment and rehabilitation plan, documented on January 19, 2021, did not include the type and frequency of the rehabilitation services to be provided to the client.
Client #13 was admitted on October 6, 2020 and was a current client at the time of the inspection. A comprehensive treatment and rehabilitation plan, documented on October 8, 2020, did not include the type and frequency of the rehabilitation services to be provided to the client.
Client #14 was admitted on March 10, 2021 and was an active client at the time of the inspection. A comprehensive treatment and rehabilitation plan, documented on March 11, 2021, did not include the type and frequency of the rehabilitation services to be provided to the client.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
In a Clinical Team meeting on 5/6/21, the project's Policies and Procedures around Treatment and Rehabilitation Management were distributed and reviewed. The role of services offered as part the treatment planning process were reviewed. Additionally, the rationale behind documenting the type and frequency of such services was provided. Clinical Director will audit all client treatment planning records to ensure type and frequency of services are included for the next 4 months, or until these elements of the plan are being completed 100% of the time over a 2 week period. |
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.
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Observations
Based on the review of client records, the project failed to reviewed and updated treatment and rehabilitation plans at least every 60-days in four of seven applicable client records reviewed.
Client #8 was admitted on December 3, 2019 and was discharged on July 27, 2020. An updated treatment and rehabilitation plan was documented in the record on February 7, 2020 and the next update was due no later than April 7, 2020; however, an updated treatment and rehabilitation plan was not documented in the record until May 6, 2020. Additionally, an updated treatment and rehabilitation plan was documented in the record on May 6, 2020 and the next update was due no later than July 6, 2020; however, an updated treatment and rehabilitation plan was not documented at the time of the inspection.
Client #9 was admitted on March 11, 2020 and was discharged on November 13, 2020. An updated treatment and rehabilitation plan was documented in the record on May 20, 2020 and the next two updates were due no later than July 20, 2020 and September 20, 2020; however, an updated treatment and rehabilitation plans were not documented at the time of the inspection.
Client #10 was admitted on June 10, 2020 and was discharged on December 18, 2020. A comprehensive treatment and rehabilitation plan was documented in the record on June 10, 2020 and the next three updates were due no later than August 10, 2020, October 10, 2020 and December 10, 2020; however, an updated treatment and rehabilitation plans were not documented at the time of the inspection.
Client #13 was admitted on October 6, 2020 and was a current client at the time of the inspection. An updated treatment and rehabilitation plan was documented in the record on October 12, 2020 and the next update was due no later than December 12, 2020; however, an updated treatment and rehabilitation plan was not documented in the record until January 26, 2021. Additionally, an updated treatment and rehabilitation plan was documented in the record on January 26, 2021 and the next update was due no later than March 26, 2021; however, an updated treatment and rehabilitation plan was not documented at the time of the inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
In a Clinical Team meeting on 5/6/21, the project's Policies and Procedures around Treatment and Rehabilitation Management were distributed and reviewed. Specifically, the role of treatment planning and the time frame for treatment plan reviews, was highlighted. Additionally, the rationale behind the role of treatment planning and reviews was explained. Clinical Director will audit all client treatment planning records to ensure type and frequency of services are included for the next 4 months, or until these elements of the plan are being completed 100% of the time over a 2 week period |