INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 10, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Evolution Counseling 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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704.11(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
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Observations
Based on a review of the facility policy and procedure manual, the facility failed to develop a policy and procedure to include a comprehensive staff development program indicating who is responsible and the time frames for completion of a mechanism to collect feedback on completed training. These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the April 9, 2021 annual licensing inspection.
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Plan of Correction
The Project Director updated the Evolution Policy Manual with the following policy: All staff are required to complete and review with their direct supervisor the "Training Evaluation Form" within 30 days following the completion of any trainings. As the form states: "Please complete this training evaluation form after the completion off any training you are required to attend (both in-house and community trainings). Please provide the completed form to your direct supervisor who will review it with you in supervision and add to your personal training binder". This mechanism allows feedback for current trainings and will allow staff to work together to assess the quality of trainings and the need for additional training based on quality and depth of what they completed. This will add to the ability to accurately review trainings within an employee's annual training evaluation.This correction will be implemented as soon as it is approved no later than 5/1/2022 |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of the facility policy and procedure manual, the facility failed to provide a written plan for the coordination of client treatment and rehabilitation services to include documentation of case consultations.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director updated the Evolution Policy Manual with the following policy:
Case Consultations
Clinical case consultations between Project Director and Clinical Supervisor and/or Counselor(s) should be documented on an "Individual Supervision note" and a placed within the client record. Case consultations can occur on an as needed basis but must occur at the minimum of one per quarter. The case consultations will also be maintained on a separate binder to assure completion and proper documentation. These consultations will then be reviewed for file placement at quarterly file reviews. This correction will be implemented as the correction is approved but no later than 5/1/2022.
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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 four of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in client records # 1, 3, 4, and 5. Client # 1 was admitted on November 30, 2021 and was still active at the time of the inspection. A letter allowing admission and treatment information dated November 30, December 31, 2021 January 31, February 28, 2022 to "To whom it may concern" was documented in the client record without a valid informed and voluntary consent from the client for the disclosure of information. Informed and voluntary consent forms in the client records included the verbiage "...not allowed to revoke the release if client has been mandated into treatment as a result of a criminal proceeding".Client # 3 was admitted on October 4, 2021 and was still active at the time of the inspection. A letter allowing admission and treatment information dated October 4, November 30, December 31, 2021, February 28, 2022 to "To whom it may concern" was documented in the client record without a valid informed and voluntary consent from the client for the disclosure of information. Client # 4 was admitted on September 1, 2021 and was still active at the time of the inspection. A letter allowing admission and treatment information dated September 2, September 30, October 29, November 30, December 31, 2021, January 31, February 28, 2022 to "To whom it may concern" was documented in the client record without a valid informed and voluntary consent from the client for the disclosure of information. Client # 5 was admitted on July 12, 2021 and was discharged on December 29, 2021. A letter allowing admission, discharge and treatment information dated December 27, 2021, to "To whom it may concern" was documented in the client record without a valid informed and voluntary consent from the client for the disclosure of information. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All release and disclosure of information must have a documented voluntary consent from the client for the disclosure of information and must be specific to the person and address which information is being released to. No information will be released without the completed voluntary release for a specific person, agency (as applicable) and address. Any information released will be checked for the accompanying release during quarterly client record review checks. This correction will be implemented as the correction is approved but no later than 5/1/2022. |
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 seven of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the specific information disclosed to a government agency be limited to 255.5 (b) .Client # 1 was admitted on November 30, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated November 30, 2021 allowed for the type of relapse be released to a funding source and county agency.Client # 2 was admitted on February 10, 2022 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated February 10, 2022 allowed for the type of relapse be released to a funding source and county agency.Client # 3 was admitted on October 4, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated October 4, 2021 allowed for the type of relapse be released to a funding source and county agency.Client # 4 was admitted on September 1, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated September 10, 2021 allowed for the type of relapse be released to a funding source and county agency.Client # 5 was admitted on July 12, 2021 and discharged on December 29, 2021. An informed and voluntary consent from the client for the disclosure of information dated July 12, 2021 allowed for the type of relapse be released to a funding source. Client # 6 was admitted on June 1, 2021 and discharged on November 9, 2021. An informed and voluntary consent from the client for the disclosure of information dated June 1, 2021 allowed for the type of relapse be released to a funding source, county agency, and parole. Client # 7 was admitted on August 23, 2021 and discharged on November 3, 2021. An informed and voluntary consent from the client for the disclosure of information dated September 8, 2021 allowed for the type of relapse be released to a funding source and county agency. These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the April 9, 2021 annual licensing inspection.
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Plan of Correction
All "Consent for the release/ disclosure of information" documents will be edited by the Project Director and Counselor to delete the following information: type of relapse be released to a funding source and county agency (or any other agency which may be identified as pertinent to the client). It is clearly understood this is not allowable and will be deleted moving forward in all paperwork. This correction will be implemented as the correction is approved but no later than 5/1/2022. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record to include a dated signature of the client but instead had "telehealth signature".Client # 2 was admitted on February 10, 2022 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated February 10, 2022 to an emergency contact did not have a valid signature by the client but instead had "telehealth" in the signature line.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All "Consent for the release/ disclosure of information" must have a documented, voluntary signed consent from the client for the disclosure of information and must be specific to the person and address which information is being released to. No information will be released without the completed voluntary, signed release for a specific person, agency (as applicable) and address. Any information released will be checked for the accompanying release during quarterly client record review checks. This correction will be implemented as the correction is approved but no later than 5/1/2022. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on one of one applicable client record reviewed, the facility failed to provide documentation of the project notifying the client, in writing, of a decision to involuntarily terminate the client's treatment in client record # 7.Client # 7 was admitted on August 23, 2021 and discharged on November 3, 2021. There was no documentation in the client record notifying the client in writing of termination from the project.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project director updated the Evolution Policy Manual regarding termination of services to state:
Involuntary Discharge
Within 5 days of involuntary discharge, communication in the form of a letter will be sent to the client who was involuntarily discharged. This letter will contain, at the minimum, reason for discharge, the unmet treatment needs and information of how to access further resources, should they choose. If a different level of care is determined to be necessary, this will also be explained and provider options will be offered (to assist referral process) and shared. Copy of letter will be kept under the correspondence section of the file. If the client responds, facility will make agreed upon referral to a different provider and appropriate level of care.
Correction will be implemented upon approval no later than 5/1/2022.
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709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Based on a review of client records, the facility failed to provide documentation of an unusual incident dated October 15, 2021 involving death or serious injury due to trauma, suicide, medication error or unusual circumstances being reported to the department within 3 business days. An unusual incident for client # 7 was sent to the funding agency but was not sent to the department.Client # 7 was admitted on August 23, 2021 and discharged on November 3, 2021.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project director will review "Reporting of Unusual Incidents" policy with facility staff and clarify an attempted overdose by a client is an incident which needs reported to both the state and funding source. Project director will assure to review all unusual incident reports after completion. It is clearly understood the error that was made. This will all occur upon approval of correction no later than 5/1/2022. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on seven of seven client records reviewed, the facility failed to provide a preliminary treatment plan according to the facility policy and procedure manual. The policy and procedure manual indicates a preliminary treatment plan be completed on the final assessment appointment.Client # 1 was admitted on November 30, 2021 and was still active at the time of the inspection. The final assessment appointment occurred on December 2, 2021 however, there was no preliminary treatment plan documented in the client record.Client # 2 was admitted on February 10, 2022 and was still active at the time of the inspection. The final assessment appointment occurred on February 10, 2022 however, there was no preliminary treatment plan documented in the client record.Client # 3 was admitted on October 4, 2021 and was still active at the time of the inspection. The final assessment appointment occurred on October 4, 2021 however, there was no preliminary treatment plan documented in the client record.Client # 4 was admitted on September 1, 2021 and was still active at the time of the inspection. The final assessment appointment occurred on September 2, 2021 however, there was no preliminary treatment plan documented in the client record.Client # 5 was admitted on July 12, 2021 and was discharged on December 29, 2021. The final assessment appointment occurred on July 13, 2021 however, there was no preliminary treatment plan documented in the client record.Client # 6 was admitted on June 1, 2021 and discharged on November 9, 2021. The final assessment appointment occurred on June 1, 2021 however, there was no preliminary treatment plan documented in the client record.Client # 7 was admitted on August 23, 2021 and discharged on November 3, 2021. The final assessment appointment occurred on August 23, 2021 however, there was no preliminary treatment plan documented in the client record.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project director revised Evolution Policy Manual to eliminate requirement of preliminary treatment plan due to no state requirement for this documentation. Project director collaborated with facility staff in making this edit to assure this is in best interest of clients. The following is what manual will state moving forward:
Treatment Planning
A comprehensive treatment plan will then be developed between the client and the counselor. This will include a problem list identified during the intake, assessment, admission process. Defined goals, objectives and interventions will be listed in the plan. This shall be completed within 15 days of admission. The client shall sign the treatment plan acknowledging his or her role in the process.
This correction will be implemented upon approval but no later than 5/1/2022. |
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 three of five applicable client records reviewed, the facility failed to provide documentation of a treatment and rehabilitation plan being reviewed and updated at least every 60 days in client records # 1, 4, and 6. Client # 1 was admitted on November 30, 2021 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on December 14, 2021. A treatment and rehabilitation plan update was due no later than February 14, 2022 however, there was no treatment and rehabilitation update in the client record.Client # 4 was admitted on September 1, 2021 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on November 19, 2021. A treatment and rehabilitation plan update was due no later than January 19, 2022 however, there was no treatment and rehabilitation update in the client record.Client # 6 was admitted on June 1, 2021 and discharged on November 9, 2021. A treatment and rehabilitation plan was developed on August 12, 2021. A treatment and rehabilitation plan update was due no later than October 8, 2021 however, there was no treatment and rehabilitation update in the client record.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project director reviewed "Treatment/Rehabilitation Management Policy" section titled Treatment Plan Reviews with counselor and concluded the counselor will review with direct supervisor needed treatment plan updates for upcoming month on a monthly basis prior to completion of any case consultation. The following month this meeting will include assuring the plan updates have been completed and continue to review needed updates for the upcoming month. This plan will be reoccuring moving forward. Correction will be implemented upon approval but no later than 5/1/2022. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on two of two applicable client records reviewed, the facility failed to provide an aftercare plan in accordance with the facility policy and procedure. The facility policy and procedure indicate an aftercare plan occur with the client before discharge and no later than the next to last appointment.Client # 5 was admitted on July 12, 2021 and was successfully discharged on December 29, 2021. There was no aftercare plan documented in the client record.Client # 7 was admitted on August 23, 2021 and discharged on November 3, 2021. Client # 7 was administratively discharged with the ability to provide an aftercare plan; however, no aftercare plan was documented in the client record.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project director reviewed the Evolution Policy titled "Project Management Services Rehabilitation Policies" section Aftercare Policy with counselor. Decision was made to implement an "Aftercare Plan" document which details goals completed during therapy, ongoing goals that have not been completed, and resources to complete ongoing goals outside of the current therapeutic setting. This form will be provided to the client for completion and subsequently reviewed with them in session. The form will be provided no later than the next to last appointment per the Evolution policy as applicable. Correction will be implemented upon approval but no later than 5/1/2022. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on two of two applicable client records reviewed, the facility failed to provide follow-up information in accordance with the facility policy and procedure. The facility policy and procedure indicate follow-up information occur within 10 days of discharge by letter or if a referral was provided the follow-up will occur within one week and documented in a progress note.Client # 5 was admitted on July 12, 2021 and was successfully discharged on December 29, 2021. There was no follow-up information documented in the client record.Client # 7 was admitted on August 23, 2021 and discharged on November 3, 2021. There was no follow-up information documented in the client record.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project director collaborated with facility staff which resulted in Evolution Policy Manual changes for follow up process as determined below:
Follow Up Policy
Evolution Counseling Services, LLC Substance Outpatient Services shall provide thorough and consistent care to all individuals who receive care. This care and concern shall be available to client both during and after treatment is terminated. All clients who receive treatment through Evolution Counseling Services, LLC Substance Outpatient Services shall be provided with continued contact to monitor ongoing success or therapy needs.
After completing treatment, regardless of type of discharge, clients shall be contacted to assess further needs, monitor quality of programs and services, and offer ongoing support.
Satisfactory Completion of Treatment
The administrative specialist within the facility will be conduct the following process:
Counselor will email weekly discharge dates to administrative specialist. Within ten calendar days of discharge from the program, each client shall be sent a letter acknowledging their completion of treatment along with encouragement to contact the program for any further assistance needed. If the client does not have a physical address to mail the letter, a phone call outreach will be provided to communicate the same information which the letter provides.
A copy of the follow up letter shall be kept in the client record (with documentation of phone follow up outreach as applicable) and any further verbal communication which may occur as part of the follow up will be documented on a progress note and kept in the client record.
Facility will implement correction upon approval but no later than 5/1/2022.
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