INITIAL COMMENTS
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This report is a result of an on-site follow-up inspection conducted on September 4, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Cornell Abraxas I 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 a review of client records, the facility failed to obtain a consent to release information form prior to releasing information in two of seven records.
Client #1 admitted on April 25, 2024 and still a current client. A release of information was signed for the client's parent on August 16, 2024 but disclosures were confirmed on May 22, June 19, July 1, and July 17.
Client #6 admitted on May 14, 2024 and discharged August 14, 2024. There was no consent to release information for a government agency, but disclosures were confirmed on July 2, July 30, and August 5.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the February 14, 2024 annual licensure inspection.
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Plan of Correction
By November 1, 2024, Treatment Supervisors will inspect each client file to verify complete and accurate consent to release information forms have been completed for all necessary parties. Treatment Supervisors will verify this process was completed during supervision with the Drug and Alcohol Treatment Program Manager.
By November 1, 2024, the Drug and Alcohol Treatment Program Manager will conduct case management training with Counselors and Treatment Supervisors to include the requirement that consent to release information forms must be completed prior to releasing verbal or written client information.
Treatment Supervisors will continue to monitor completion of consent to release information forms during monthly chart audits. The Program Manager is responsible for oversight of this process. She will verify the Treatment Supervisors' chart reviews have been completed during monthly supervision and document in a supervisory conference note. The facility will be in full compliance with the standard by November 1, 2024
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709.34 (c) (1) 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:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on a review of administrative information, the facility failed to inform the Department of an unusual incident. The facility had an unusual incident occur on July 5 and July 20, 2024 which involved physical assault of a client and the facility did not submit an incident report to the Department.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
By November 1, 2024, the Executive Director, the Drug & Alcohol Program Manager and the Quality & Compliance Specialist will review the standard and policy regarding the submission of unusual incident reports, to include the types of incidents requiring a report. Reports of unusual incidents will be made to the Quality & Compliance Specialist who will enter the report into the online portal. The Executive Director and Drug & Alcohol Program Manager will complete reports if the Quality & Compliance Specialist is not available.
The Executive Director will be responsible for oversight of this process. The facility will be in full compliance with the standard by November 1, 2024.
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709.34 (c) (4) 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:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of administrative information, the facility failed to inform the Department of an unusual incident. The facility had an unusual incident occur on July 6, July 8, and July 22, 2024 all which involved police onsite and the facility did not submit an incident report to the Department.
This finding was reviewed with the facility staff during the licensing process.
This is a repeat citation from the February 14, 2024 annual licensure inspection.
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Plan of Correction
By November 1, 2024, the Executive Director, the Drug & Alcohol Program Manager and the Quality & Compliance Specialist will review the standard and policy regarding the submission of unusual incident reports, to include the types of incidents requiring a report. Reports of unusual incidents will be made to the Quality & Compliance Specialist who will enter the report into the online portal. The Executive Director and Drug & Alcohol Program Manager will complete reports if the Quality & Compliance Specialist is not available.
The Executive Director will be responsible for oversight of this process. The facility will be in full compliance with the standard by November 1, 2024.
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709.53(a)(5) LICENSURE Progress Notes
709.53. 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:
(5) Progress notes.
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Observations
Based on a review of client records, the facility failed to provide a complete client record to include progress notes that are reflective of the clients' services received in four of seven records.
Client #3 was admitted on May 30, 2024 and still a current client. The record of services identified individual sessions on the following dates but there were no corresponding progress notes in the client record: July 8 and August 5, 2024.
Client #4 was admitted on May 10, 2024 and still a current client. The record of services identified individual sessions on the following dates but there were no corresponding progress notes in the client record: July 9 and August 8, 2024.
Client #5 was admitted on May 1, 2024 and still a current client. The record of services identified individual sessions on the following dates but there were no corresponding progress notes in the client record: May 13, June 11, June 27, July 10, August 9, August 14, and August 21, 2024.
Client #7 was admitted on April 25, 2024 and discharged on August 16, 2024. The record of services identified individual sessions on the following dates but there were no corresponding progress notes in the client record: July 26, and August 2, 2024.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the February 14, 2024 annual licensure inspection.
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Plan of Correction
By November 1, 2024, the Drug and Alcohol Program Manager will complete a review of the Record Keeping Policy with all Counselors and Treatment Supervisors, to include the requirement that progress notes must be completed for each individual counseling session, documented on the Record of Service, and filed on time in the client file.
Treatment Supervisors will each complete a minimum of 3 file reviews per month (total of 6 per dorm) to verify that progress notes are completed and filed for individual counseling sessions and documented on the Record of Service.
The Program Manager is responsible for oversight of this process. She will verify the Treatment Supervisors' chart reviews have been completed during monthly supervision and document in a supervisory conference note. The facility will be in full compliance with the standard by November 1, 2024.
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