INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, 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 September 17, 2020 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, Hispanic American Organization Inc. 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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709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on an administrative review, the project failed to ensure that the project director annually updated and signed the written manual delineating the project's policies and procedures.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The organization Program Director will submit review written manual delineating the project's policies and procedures annually to the board of directors. This process will take place by the 2nd week of the January each year.
For 2020 the review was completed on January 2020, unfortunately a copy was not available at the time of review in the facility. |
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 facility failed to document the specific information to be released on consent to release information forms in one of seven client records reviewed.
Client # 7 was admitted on August 8, 2019 and was discharged on December 5, 2019. A release of information form to another treatment provider was signed and dated by the client and witness on August 8, 2019. Also, a release of information form to a parole officer was signed and dated by the client and witness on September 9, 2019. Both forms failed to include the specific information to be disclosed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The counseling staff will complete a PA TRAIN: training on Confidentiality by 10-21-2020. Training will address the documentation of specific information to be released on consent to release information forms.
All release of information will be included as part of the QA review of all intakes and assessment completed weekly. The Clinical Supervisor and supervision will be provided on compliance with Release of information completion accurate and in a timely manner. |
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 a review of client records, the facility failed to ensure that treatment plan updates were reviewed and updated at least every sixty days in two of four applicable client records reviewed.
Client #3 was admitted on March 12, 2020 and was still active at the time of the inspection. A treatment plan update was completed on May 14, 2020 with another update due no later than July 14, 2020. There was no treatment plan update at the time of the inspection.
Client #5 was admitted on October 17, 2019 and was discharged on June 25, 2020. A treatment plan update was completed on March 31, 2020 with another update due no later than May 31, 2010. There was no update prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor and the Counseling team had enter reminders in Electronic Record review to ensure that treatment plan updates are reviewed and updated at least every sixty days.
Clinical supervisor will review cases prior to Discharge to ensure that 60 days review are completed prior to discharges if they are due.
Client #5 treatment plan was update and resubmitted on 10/21/2020, the date of the review completed as of March 29, 2020.
Client #3 treatment plan was updated and resubmitted on 10/21/2020, the date of the review completed as of March 29, 2020.
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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 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 17, 2019 and was discharged on August 7, 2020. There was no follow-up information in the client record at the time of the inspection.
Client #5 was admitted on October 17, 2019 and was discharged on June 25, 2020. There was no follow-up information in the client record at the time of the inspection.
Client #6 was admitted on October 30, 2019 and was discharged on May 27, 2020. There was no follow-up information in the client record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The organization had implemented a electronic record form for Follow ups, that will be added to the counselors electronic files upon discharge to be completed after the 2nd week after discharge date. These process will remind the counselor of completion of follow ups are due.
The clinical supervisor will be responsible for implementation of this corrective action plan.
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