INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 8, 2022 through November 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, St. Luke's Penn Foundation 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(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to ensure that each employee had a written, annual individual training plan, with input from the employee and supervisor, documented in one of twenty personnel records reviewed.Employee #16 was hired as a counselor on November 29, 2021. There was no documentation in the personnel record that the individual training plan was completed with input from the employee's supervisor.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
By 12/1/2022, Clinical Supervisors will ensure that when completing Individualized Training Plans (ITP), both staff and the supervisor will sign and date the ITP at the time of completion with the staff. The department secretary will audit completed ITPs to ensure they are signed accordingly. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on an administrative review of the facility's November 2021 through October 2022 outpatient fire drill logs, the facility failed to identify, on each fire drill log, either which exit route was used and/or amount of time it took for evacuation. The December 2021, January 2022, March 2022 and May 2022 fire drill logs did not document which exit route was used. Additionally, the December 2021, January 2022 and March 2022 fire drill logs did not document the amount of time it took for evacuation.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 12/1/2022, maintenance department will be re-trained staff on properly conducting fire drills at the outpatient locations. The Maintenance Department supervisor was made aware that verbal drills are not to be conducted and that the persons occupying the building at the time of the drill will be evacuated. Supervisor will review with the department how to properly fill out the fire drill log form. Practice Administrator at the sites will review the form monthly for compliance. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on an administrative review of the facility's residential activity's November 2021 through October 2022 fire drill logs, the facility failed to conduct a fire drill during sleeping hours at least every 6 months. There were overnight fire drills conducted in September 2022 and October 2022 during the timeframe reviewed; however, the overnight drills did not occur at least every 6 months. This is a repeat citation from the October 27, 2021 through October 29, 2021 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 12/1/2022, the maintenance supervisor will re-train facilities staff on regulations related to conducting fire drills in the residential setting, specifically conducting fire drills a minimum of one time every six months during hours of sleep. The maintenance supervisor will review completed fire drill logs, monthly, to ensure compliance. |
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 a review of client records, the facility failed to obtain an informed and voluntary consent to release information form prior to the disclosure of information in two of twenty-eight client records reviewed.Client #12 was admitted to the intake, evaluation, and referral activity on August 1, 2022 and was discharged on August 9, 2022. There was documentation of billing to the funding source; however, there was no release of information form documented in the record prior to the disclosure. Client #15 was admitted to the detoxification activity on November 2, 2022 and was active at the time of inspection. There was documentation of billing to the funding source; however, there was no release of information form documented in the record prior to the disclosure.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 12/15/2022, all staff who complete Consent to Release Information forms will be retrained in requirements for completing release forms in order to disclose confidential information, the workflow for completing consent to release forms will be reviewed as well. By 12/15/2022, the Accreditation & Standards Coordinator will conduct monthly chart audits in conjunction with the audit committee to monitor compliance and initiate action in conjunction with the supervisor when non-compliance is identified.
Client #12 has not been in services since 8/2022. No future disclosures will be made to the funding source unless a consent in signed.
Client #15 sign a consent to release information for the funding source on 11/9/2022. |
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 a review of client records, the facility failed to document the dated signature of the client on release of information forms in one of twenty-eight client records reviewed.Client #27 was admitted to the inpatient program on June 22, 2022 and was discharged on July 13, 2022. The release of information form to an emergency contact was signed by a witness on June 17, 2022; however, there was no dated client signature.This is a repeat citation from the January 6, 2020 - January 9, 2020, October 1, 2020, and October 27, 2021 - October 29, 2021 annual licensing renewal inspections.The finding was reviewed with facility staff during the licensing process.
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Plan of Correction
By 12/15/2022, all staff who complete Consent to Release Information forms will be retrained to review requirements for completing release forms. By 12/15/2022, the Accreditation & Standards Coordinator will conduct chart audits in conjunction with the audit committee to monitor compliance and initiate action when non-compliance is identified. By 1/1/2023, adjustments will be made to the electronic health record to require supervisor approval of all Consent to Release Information forms, supervisor will check for client and witness signature, if either signature is missing, supervisor will create a "red x" and notify the staff person to obtain the signature. Once corrected the supervisor will approve the document. Compliance will be monitored via monthly chart audits by the Accreditation & Standards Coordinator and reviewed in the monthly audit committee. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to assure that counseling services were being provided according to the individual treatment and rehabilitation plan in two of four applicable client records reviewed.Client #2 was admitted on August 23, 2022 and was active at time of inspection. The individual treatment plan, dated September 20, 2022, indicated the client was to receive one individual counseling session per week. The client's record of service and progress notes indicated that the client had received no individual counseling sessions during the entire month of October 2022.Client #4 was admitted on June 3, 2022 and discharged on September 9, 2022. The individual treatment plan, dated June 17, 2022, as well as the updated treatment plan, dated August 18, 2022 indicated the client was to receive two individual counseling session per month. The client's record of service and progress notes indicated that the client had received only one session for the month of August.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 12/15/2022, Clinical supervisors will conduct clinician staff training to ensure client scheduling occurs in accordance with what the treatment plan indicates. If a client is not meeting with the clinician, the clinician will document the reason services have not been provided (client vacation, incarceration, etc.). Treatment plans will be updated if a change in type and frequency of a client's treatment occurs. Clinical supervisors will conduct monthly chart audits to ensure compliance with the regulation.
Client #2 and his counselor reviewed and updated the treatment plan on 11/1/2022, frequency of individual counseling was updated to 1 time per month. Per the chart client was seen for an individual session on 11/1/2022 and is scheduled for his next individual session on 11/30/2022.
Client #4 was discharged on 9/9/2022 and has not re-engaged in services as of this date. |
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 a review of client records, the facility failed to a maintain a complete client record on an individual, which is to include an aftercare plan, in two of two applicable client records reviewed.Client #4 was admitted on June 3, 2022 and discharged on September 9, 2022Client #7 was admitted on April 1, 2022 and was discharged on June 13, 2022.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 12/15/2022, Clinical Supervisors will review with medical receptionists and clinicians in team meeting properly filling out the discharge summary to include the client's aftercare plans. If aftercare has not be discussed with the client and formalized the clinician will include a statement in the discharge summary that indicates this. The clinical supervisor will monitor compliance via monthly chart audits. |
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 a review of client records, the facility failed to a maintain a complete client record on an individual, which is to include follow-up information, in three of four applicable client records reviewed.Client #4 was admitted on June 3, 2022 and discharged on September 9, 2022Client #6 was admitted on July 11, 2022 and was discharged on September 6, 2022.Client #7 was admitted on April 1, 2022 and was discharged on June 13, 2022.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 12/15/2022 Medical receptionists will be re-trained in completing follow up calls to ensure clients were successfully connected to their aftercare plans. The calls will be conducted within 7 days of discharge. Documentation will be listed in the client record. Clinical supervisors will conduct monthly chart audits to ensure compliance with this regulation. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department. Plans of correction for documenting the dated signature of the client on release of information forms were submitted and approved by the Department for the October 27, 2021 - October 29, 2021, October 1, 2020, and January 6, 2020 - January 9, 2020 annual licensing inspections. Documenting the dated signature of the client on release of information forms was again found to be a deficiency in the November 8, 2022 through November 10, 2022 licensing inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Corrective action will include: By 1/1/2023, adjustments will be made to the electronic health record to require supervisor approval of all Consent to Release Information forms, supervisor will check for client and witness signature, if either signature is missing, supervisor will create a "red x" and notify the staff person to obtain the signature. Once corrected the supervisor will approve the document. Additionally, by 12/15/2022, all staff who complete Consent to Release Information forms will be retrained to review requirements for completing release forms. By 12/15/2022, the Accreditation & Standards Coordinator will conduct chart audits in conjunction with the audit committee to monitor compliance and initiate action when non-compliance is identified. Compliance will be monitored via monthly chart audits by the Accreditation & Standards Coordinator and reviewed in the monthly audit committee. |