INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 25, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Engagement, 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 three of seven records reviewed.
Client #2 was admitted on March 14, 2024, and was a current client at the time of the licensing inspection. A release of information form for the funding source was not documented in the client record; however, the facility verified that billing had occurred.
Client #6 was admitted on April 23, 2024, and was discharged on July 31, 2024. A release of information form for the funding source was not documented in the client record; however, the facility verified that billing had occurred.
Client #7 was admitted on May 14, 2024, and was discharged on August 9, 2024. A release of information form for the funding source was not documented in the client record; however, the facility verified that billing had occurred.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Client # 2 an Client #6 and Client 7 were notified that we had failed to appropriate ROI's for billing heir insurances. They were provided information to be able to come into the office to sign a ROI for their insurance companies, as well as notified of their rights. Since client # 2 had not been discharged at the time of at the inspection, that client was informed that the ROI was not obtained, and asked to sign an ROI for the insurance company. To prevent further issues with ROI's and confidentiality. A training was provided during the staff meeting on 10/04/2024. The facility director provided staff members were informed of the process that Engagement LLC uses to obtain ROI's for funding, and all other confidential communication through the EMR we utilize to maintain chart records. The facility director will conduct 60 day reviews to verify the ROI's are being obtained and communicated correctly. Once this is seen to be consistent for 90 days, the reviews will become part of the quarterly review that is conducted by the facility director for quality improvement. |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on the review of client records, the project failed to document written acknowledgement by clients that the clients have the right to inspect their own records and that the project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental in if presented to the client in seven of seven client records reviewed.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Facility Director updated the clients rights in the EMR to include written acknowledgement by clients that the clients have the right to inspect their own records and that the project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental in if presented to the client. This updated client rights was communicated to any of the clients in services. To ensure the client rights continue to maintain the totality of the client rights information as noted above, inspection of the client rights materials will be verified in quarterly QI reviews completed by the facility director. The next review will occur on 10/12/1024. |
709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on the review of client records, the project failed to document written acknowledgement by clients that the clients have the right to appeal a decision limiting access to their records to the director in seven of seven client records reviewed.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Facility Director updated the clients rights in the EMR to include written acknowledgement by clients that the clients have the right to appeal a decision limiting access to their records to the director. This updated client rights was communicated to any of the clients in services. To ensure the client rights continue to maintain the totality of the client rights information as noted above, inspection of the client rights materials will be verified in quarterly QI reviews completed by the facility director. The next review will occur on 10/12/1024. |
709.30 (5) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Based on the review of client records, the project failed to document written acknowledgement by clients that the clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records in seven of seven client records reviewed.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Facility Director updated the clients rights in the EMR to include written acknowledgement by clients that the clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records. This updated client rights was communicated to any of the clients still in services. To ensure the client rights continue to maintain the totality of the client rights information as noted above, inspection of the client rights materials will be verified in quarterly QI reviews completed by the facility director. The next review will occur on 10/12/1024. |
709.30 (6) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on the review of client records, the project failed to document written acknowledgement by clients that the clients have the right submit a rebuttal data or memoranda to their own records in seven of seven client records reviewed.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Facility Director updated the clients rights in the EMR to include written acknowledgement by clients that the clients have the right to submit a rebuttal data or memoranda to their own records in seven of seven client records reviewed. This updated client rights was communicated to any of the clients still in services. To ensure the client rights continue to maintain the totality of the client rights information as noted above, inspection of the client rights materials will be verified in quarterly QI reviews completed by the facility director. The next review will occur on 10/12/1024. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records and the project ' s policies and procedures, the project failed to document a completed psychosocial evaluation at admission, per policy, in four of seven client records reviewed.
Client #2 was admitted on March 14, 2024, and was a current client at the time of the licensing inspection. A psychosocial evaluation was not completed.
Client #3 was admitted on April 23, 2024, and was a currently client at the time of the licensing inspection. A psychosocial evaluation was not completed.
Client #4 was admitted on January 18, 2024, and was discharged on April 25, 2024. A psychosocial evaluation was not completed.
Client #5 was admitted on March 26, 2024, and was discharged on August 5, 2024. A psychosocial evaluation was not completed.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The facility Director provided a staff training that occurred on 10/18/2024 to address the issue of clinical summary's not being completed at the time of the level of care assessment / biopsychosocial, or not having enough detail in said clinical summary. Staff were training to include details of who referred the client for services, to include a brief picture of current and past substance usage, any associated problems, to include social, work, and family. As well as any deficits or skills in coping strategies, and healthy or unhealthy supports. Clinical summaries will be included in chart reviews completed by the Facility Director on a monthly basis, until the summaries are seen to be completed correctly. Then the clinical summary will be included in the quarterly review the facility director completes. The next monthly review will occur 10/31/2024. |
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 a review of client records and the project ' s policies and procedures, the project failed to document a preliminary treatment plan at the client ' s first treatment visit in three of seven client records reviewed.
Client #4 was admitted on January 18, 2024, and was discharged on April 25, 2024. A preliminary treatment plan was not documented in the client record.
Client #5 was admitted on March 26, 2024, and was discharged on August 5, 2024. A preliminary treatment plan was not documented in the client record.
Client #6 was admitted on April 23, 2024, and was discharged on July 31, 2024. A preliminary treatment plan 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
On 10/04/2024 the facility director provided a training to all counselors instructing them on the process of utilizing the updated documentation in the biopsychosocial to include preliminary treatment plan language, specific to clients that are recommended to SUD treatment services. Individuals will be instructed to remain substance free, from all illicit, non prescribed medication, or any other non prescribed mood altering substances, as well as using said medication as directed. Information has been added to the psychosocial evaluation to include notification of the preliminary treatment plan, and include the recommendation of group and individual services, as appropriate. Information has also been added to include general goals for further development of relapse prevention strategies for emotional, situational, and/or physical cravings or other life stressors, as appropriate to each client.
The facility director will verify use of preliminary treatment plan documentation is completed, though the quarterly QI process. The next review will Occur 10/12/2024. |
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 facility failed to review and update treatment and rehabilitation plans at least every 60 days in four of seven records reviewed.
Client #2 was admitted on March 14, 2024, and was a current client at the time of the licensing inspection. A comprehensive treatment and rehabilitation plan was documented in the record on March 22, 2024, and the update was due no later than May 22, 2024; however, there was no updated plan documented in the record at the time of the inspection.
Client #3 was admitted on April 23, 2024, and was a currently client at the time of the licensing inspection. A comprehensive treatment and rehabilitation plan was documented in the record on April 23, 2024, and the update was due no later than June 23, 2024; however, the updated plan was not documented in the record until August 19, 2024.
Client #6 was admitted on April 23, 2024, and was discharged on July 31, 2024. A comprehensive treatment and rehabilitation plan was documented in the record on May 21, 2024, and the update was due no later than July 21, 2024; however, there was no updated plan documented in the record at the time of the inspection.
Client #7 was admitted on May 14, 2024, and was discharged on August 9, 2024. A comprehensive treatment and rehabilitation plan was documented in the record on May 21, 2024, and the update was due no later than July 21, 2024; however, there was no updated plan documented in the record at the time of the inspection.
This is a repeat citation from the October 10, 2023 annual licensing renewal inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
On 10/04/2024 a staff training for all counselors occurred and instructed in the process of treatment plan reviews being completed before or on 60 day time frame from the creation of the Master treatment plan. Several methods, such as Excel spread sheet has been created by the facility director and given to the counselors to use in order to track the time frames needed for Treatment plan reviews. On the other hand, they can use another method, such as keeping track of the time frames on their electronic work calendars. Counselors were required to pick a process they will be using. The counselors discussed the choice and began using it that day. The facility director will initially verify though a QI process monthly for 3 months, to verify the process is working to obtain the treatment plan reviews per our policy. IF not other methods will be utilized, if the treatment plan reviews are being completed per policy, the review by the facility director will go back to the quarterly review time frame. In order to verify the process is still occurring as needed. |