INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 13, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, RHD Lower Marion Counseling Services 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 the Staffing Requirements Facility Summary Report and personnel records, the facility failed to have written individual training plans for each employee, to be developed with input from both the employee and the supervisor in five of fourteen personnel records reviewed.
Employee#6 was hired as a counselor on December 12, 2022. There was no documentation of a training plan, in the record, for the facility's current training year.
Employee#15 was hired as a medical assistant on October 17, 2022. There was no documentation of a training plan, in the record, for the facility's current training year.
Employee#16 was hired as a medical assistant on July 7, 2022. There was no documentation of a training plan, in the record, for the facility's current training year.
Employee#17 was hired as a nurse on July 25, 2022. There was no documentation of a training plan, in the record, for the facility's current training year.
Employee#18 was hired as the intake coordinator on January 9. 2023. There was no documentation of a training plan, in the record, for the facility's current training year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The supervisor for employee 6 (Clinical Supervisor) and the supervisor for employees 15, 16, & 17 (CCBHC-E Grant Project Director), will complete and submit training plans to the Quality Assurance Manager to be stored in the staff's respective files. All training plans will be due by 4/14/23.
New Hire Onboarding Policy & Procedures will be updated by the Quality Assurance Manager and the Clinical Director, under the review of the LMCMS Policy Group, by 5/10/23 to state that initial training plans will be a required component of new hire onboarding process. Training plans will be completed for all staff
within two business weeks of hire and will be submitted to the Quality Assurance Department for completeness review and storage in staff records.
Training plans will be updated annually for all employees with their respective supervisors at the beginning of every new fiscal year (July) in conjunction with annual performance evaluations. All training plans will be submitted to the Quality Assurance Department for completeness review and storage in staff records within 60 days of the start of the new fiscal year.
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of the Staffing Requirement Facility Summary Report and personnel records, the facility failed to ensure that all staff received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory time frame in two of six applicable personnel records reviewed.
Employee #4 was hired as a clinical supervisor on April 19, 2021. The TB/STD training was due no later than April 19, 2022. However, the training was not completed as of the date of the inspection.
Employee #10 was hired as a counselor on March 8, 2021. The HIV/AIDS training and the TB/STD training was due no later than March 8, 2022. However, neither of the trainings were completed as of the date of the inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Employees 4 and 10 are registered to take the TB/STD training through DDAP on 5/26/23. Employee 10 is scheduled to receive the HIV/AIDS disease training by 4/14/23. Awarded training certificates with the number of training hours will be submitted to the Clinical Director for review and to the Quality Assurance Manager for storage in the staff records.
New hire policies and procedures for onboarding will be updated by the Director of Operations, the Quality Assurance Manager and the Clinical Director, under the review of the LMCMS Policy Group, by 5/10/23 to require that all new hires for positions that interact with D&A individuals will be required to sign up for the next available mandatory communicable disease trainings at onboarding. Awarded training certificates with the number of training hours will be submitted to the Clinical Supervisor for review and to the Quality Assurance Manager for storage in the staff records.
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report and personnel records, the facility failed to ensure that each counselor completed at least 25 clock hours of annual training during the facility ' s January 2022 through December 2022 training year in one of four applicable personnel records reviewed.
Employee # 11 was hired as a counselor on June 14, 2021. The record documented 17 hours of annual training for the reviewed training year.
This is a repeat citation from the February 10, 2022 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All D&A staff members will submit their scheduled trainings at the beginning of each yearly quarter to the Clinical Supervisor. This information will be collected at the same time as the quarterly feedback survey (4/3/23). The Clinical Supervisor will submit the scheduled training hours to the Clinical Director. Within two weeks of the end of every quarter, the Clinical Supervisor and the Clinical Director will review all completed and scheduled training hours for every staff member. The first deadline for scheduled training hours to be submitted to the Clinical Supervisor will be 4/14/23. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to document that staff were instructed in the use of the fire extinguisher upon employment in two of four applicable personnel records reviewed.
Employee # 13 was hired as an intern/counselor assistant on July 7, 2022. There was no documentation of training in the use of fire extinguishers as of the date of the inspection.
Employee # 14 was hired as an intern/counselor assistant on August 1, 2022. There was no documentation of training in the use of fire extinguishers as of the date of the inspection.
This is a repeat citation from the February 10, 2022 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Employees 13 and 14 will complete the fire safety training by 4/14/23 and submit the training certificate to the Clinical Supervisor for review and to the Quality Assurance Manager for storage in the respective staff files.
LMCMS will correct the training due date for the fire safety training in the RHD training suite to ensure that the training is completed within the first two weeks of hire for all staff.
The Clinical Supervisor will receive an automated email alert from the RHD training suite at the end of every two week onboarding period for any uncompleted trainings to ensure that onboarding trainings are completed during onboarding.
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705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies in two of four applicable personnel records reviewed.
Employee # 13 was hired as an intern/counselor assistant on July 7, 2022. There was no documentation of training on the assignment of tasks during emergencies as of the date of the inspection.
Employee # 14 was hired as an intern on August 1, 2022. There was no documentation of training on the assignment of tasks during emergencies as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employees 13 and 14 will complete the fire safety training by 4/14/23 and submit the training certificate to the Clinical Supervisor for review and to the Quality Assurance Manager for storage in the respective staff files.
LMCMS will correct the training due date for the fire safety training in the RHD training suite by 4/14/23 to ensure that the training is completed within the first two weeks of hire for all staff.
The Clinical Supervisor will receive an automated email alert from the RHD training suite at the end of every two week onboarding period for any uncompleted trainings to ensure that onboarding trainings are completed during onboarding.
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705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the facility's February 2022 through February 2023 fire drill logs, the facility failed to ensure that alternate exit routes were prepared and used during fire drills for every fire drill conducted during the reviewed period.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The LMCMS Quality Assurance Manager will update the fire drill template by 4/14/23 to include instructions on using both building exits at a minimum of once per quarter during fire drills. The Director of Operations will review the fire drill log quarterly to ensure that all exits are used in fire drills as appropriate. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel files, the facility failed to ensure that annual written individual performance evaluations, reviewed and signed by the employee, were completed in three of five applicable personnel records reviewed.
Employee #1 was hired as the project director on February 18, 2018. There was no documentation, as of the date of the inspection, that an annual written individual performance evaluation was completed for the 2022 year.
Employee #2 was hired as the facility director on April 15, 2019. There was no documentation, as of the date of the inspection, that an annual written individual performance evaluation was completed for the 2022 year.
Employee #4 was hired as a clinical supervisor on April 19, 2021. There was no documentation, as of the date of the inspection, that an annual written individual performance evaluation was completed for the 2022 year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The respective supervisors of employees 1 (RHD Chief Executive Officer), 2 (RHD Regional Director), and 4 (Clinical Director) will submit by 4/21/23 the missing annual performance evaluations to the Quality Assurance Manager for review of completeness and storage in the respective staff files.
Regardless of an employee's hire date, annual performance evaluations will be conducted annually for all employees by their respective supervisors within the first 60 days of every new fiscal year. All annual performance evaluations will be submitted to the Facility Director and Director of Operations for review of completeness and signature. Annual evaluations will be submitted to the Quality Assurance Department for storage in staff records.
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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 an informed and voluntary consent from the client for the disclosure of information contained in the client record in seven of seven client records reviewed.
Each client record had evidence of billing to the client's funding source; however, there were no consent to release information forms to the client's funding source in every client record reviewed.
This is a repeat citation from the February 10, 2022 and March 2, 2021 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing inspection
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Plan of Correction
The Clinical Supervisor will obtain from every individual in service whose chart was audited an informed, voluntary consent for disclosure of information to their funding source. These signed consents will be obtained using electronic signature software and will be uploaded into the respective charts by 4/28/23.
The Clinical Supervisor will review the chart of every active individual active in service, regardless of whether the chart was part of the audit, to confirm the presence of a voluntary consent for disclosure of information to their funding source. Any individuals whose charts are missing signed voluntary consent for disclosure of information to their funding source will be sent the consent for review and signature. These signed consents will be obtained using electronic signature software and will be uploaded into the respective charts by 5/12/23.
Quarterly Compliance Reviews will be conducted by the Quality Assurance Department on a quarterly basis. These reviews will be attended by the Director of Operations, the Clinical Supervisor, the Clinical Director, and the Quality Assurance Manager. Quarterly Compliance Reviews will monitor the LMCMS Drug & Alcohol program's full and accurate implementation all POC items, including the presence of voluntary consent for disclosure of information to their funding source. The first quarterly compliance review will be conducted on 4/19/23 and every three months thereafter.
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709.30 (1) 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.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right that a client receiving care or treatment under section 7 of the act (71 P. S. 1690.107) shall retain civil rights and liberties except as provided by statute and that no client may be deprived of a civil right solely by reason of treatment in three of seven client records reviewed.
Client #2 was admitted on November 16. 2022 and was still active at the time of the inspection. There was no written client rights acknowledgement documented in the record at the time of the inspection.
Client #3 was admitted on August 24, 2022 and was still active at the time of the inspection. There was no written client rights acknowledgement documented in the record at the time of the inspection.
Client #4 was admitted on June 9, 2022 and was discharged on January 3, 2023. There was no written client rights acknowledgement documented in the record at the time of the inspection.
This is a repeat citation from the March 2, 2021 and February 10, 2022 annual licensing renewal inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
LMCMS Clinical Supervisor will collect written acknowledgement for charts 2 and 3 that they have been notified of their rights through a signed "Clients Rights and Responsibilities" and upload them into the respective charts by 4/14/23. The Clinical Supervisor will send "Clients Rights" to individuals for signature using our electronic signature software. For any individuals who are not able to, or choose not to, use the electronic signature software to sign the "Clients Right," they will have the option to either receive the packet through physical mail or come into the office to sign paper copies in person. All signed "Clients Rights," whether signed in person or electronically, will be uploaded into the respective individuals' charts by the Medical Records clerk.
All individuals in services will review and sign the "Clients Rights" at intake as part of the intake process.
When an individual enrolled in Mental Health Outpatient is identified at intake as appropriate for Drug and Alcohol services and switched into the latter service line at intake, their "Clients Rights," as part of the intake packet, will be uploaded into the Drug and Alcohol chart. The Intake Clinician responsible for switching the intake packet including signed "Client Rights" over to the new D&A Episode will alert the Clinical Supervisor that this has occurred. The Clinical Supervisor will review the new chart to ensure that the signed "Clients Rights" is present in the new chart.
Quarterly Compliance Reviews will be conducted by the Quality Assurance Department on a quarterly basis. These reviews will be attended by the Director of Operations, the Clinical Supervisor, the Clinical Director, and the Quality Assurance Manager. Quarterly Compliance Reviews will monitor the LMCMS Drug & Alcohol program's full and accurate implementation all POC items, including the presence of written acknowledgement by clients that they have been notified of their rights. The first quarterly compliance review will be conducted on 4/19/23 and every three months thereafter.
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709.30 (2) 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.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right that the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion in three of seven client records reviewed.
Client #2 was admitted on November 16. 2022 and was still active at the time of the inspection. There was no written client rights acknowledgement documented in the record at the time of the inspection.
Client #3 was admitted on August 24, 2022 and was still active at the time of the inspection. There was no written client rights acknowledgement documented in the record at the time of the inspection.
Client #4 was admitted on June 9, 2022 and was discharged on January 3, 2023. There was no written client rights acknowledgement documented in the record at the time of the inspection.
This is a repeat citation from the March 2, 2021 and February 10, 2022 annual licensing renewal inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
LMCMS Clinical Supervisor will collect written acknowledgement for charts 2 and 3 that they have been notified of their rights through a signed "Clients Rights and Responsibilities" and upload them into the respective charts by 4/14/23. The Clinical Supervisor will send "Clients Rights" to individuals for signature using our electronic signature software. For any individuals who are not able to, or choose not to, use the electronic signature software to sign the "Clients Right," they will have the option to either receive the packet through physical mail or come into the office to sign paper copies in person. All signed "Clients Rights," whether signed in person or electronically, will be uploaded into the respective individuals' charts by the Medical Records clerk.
All individuals in services will review and sign the "Clients Rights" at intake as part of the intake process.
When an individual enrolled in Mental Health Outpatient is identified at intake as appropriate for Drug and Alcohol services and switched into the latter service line at intake, their "Clients Rights," as part of the intake packet, will be uploaded into the Drug and Alcohol chart. The Intake Clinician responsible for switching the intake packet including signed "Client Rights" over to the new D&A Episode will alert the Clinical Supervisor that this has occurred. The Clinical Supervisor will review the new chart to ensure that the signed "Clients Rights" is present in the new chart.
Quarterly Compliance Reviews will be conducted by the Quality Assurance Department on a quarterly basis. These reviews will be attended by the Director of Operations, the Clinical Supervisor, the Clinical Director, and the Quality Assurance Manager. Quarterly Compliance Reviews will monitor the LMCMS Drug & Alcohol program's full and accurate implementation all POC items, including the presence of written acknowledgement by clients that they have been notified of their rights. The first quarterly compliance review will be conducted on 4/19/23 and every three months thereafter.
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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 a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right to inspect their own records and 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 and that reasons for removing sections shall be documented in the record in three of seven client records reviewed.
Client #2 was admitted on November 16. 2022 and was still active at the time of the inspection. There was no written client rights acknowledgement documented in the record at the time of the inspection.
Client #3 was admitted on August 24, 2022 and was still active at the time of the inspection. There was no written client rights acknowledgement documented in the record at the time of the inspection.
Client #4 was admitted on June 9, 2022 and was discharged on January 3, 2023. There was no written client rights acknowledgement documented in the record at the time of the inspection.
This is a repeat citation from the March 2, 2021 and February 10, 2022 annual licensing renewal inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
LMCMS Clinical Supervisor will collect written acknowledgement for charts 2 and 3 that they have been notified of their rights through a signed "Clients Rights and Responsibilities" and upload them into the respective charts by 4/14/23. The Clinical Supervisor will send "Clients Rights" to individuals for signature using our electronic signature software. For any individuals who are not able to, or choose not to, use the electronic signature software to sign the "Clients Right," they will have the option to either receive the packet through physical mail or come into the office to sign paper copies in person. All signed "Clients Rights," whether signed in person or electronically, will be uploaded into the respective individuals' charts by the Medical Records clerk.
All individuals in services will review and sign the "Clients Rights" at intake as part of the intake process.
When an individual enrolled in Mental Health Outpatient is identified at intake as appropriate for Drug and Alcohol services and switched into the latter service line at intake, their "Clients Rights," as part of the intake packet, will be uploaded into the Drug and Alcohol chart. The Intake Clinician responsible for switching the intake packet including signed "Client Rights" over to the new D&A Episode will alert the Clinical Supervisor that this has occurred. The Clinical Supervisor will review the new chart to ensure that the signed "Clients Rights" is present in the new chart.
Quarterly Compliance Reviews will be conducted by the Quality Assurance Department on a quarterly basis. These reviews will be attended by the Director of Operations, the Clinical Supervisor, the Clinical Director, and the Quality Assurance Manager. Quarterly Compliance Reviews will monitor the LMCMS Drug & Alcohol program's full and accurate implementation all POC items, including the presence of written acknowledgement by clients that they have been notified of their rights. The first quarterly compliance review will be conducted on 4/19/23 and every three months thereafter.
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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 a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right to appeal a decision limiting access to their records to the director in three of seven client records reviewed.
Client #2 was admitted on November 16. 2022 and was still active at the time of the inspection. There was no written client rights acknowledgement documented in the record at the time of the inspection.
Client #3 was admitted on August 24, 2022 and was still active at the time of the inspection. There was no written client rights acknowledgement documented in the record at the time of the inspection.
Client #4 was admitted on June 9, 2022 and was discharged on January 3, 2023. There was no written client rights acknowledgement documented in the record at the time of the inspection.
This is a repeat citation from the March 2, 2021 and February 10, 2022 annual licensing renewal inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
LMCMS Clinical Supervisor will collect written acknowledgement for charts 2 and 3 that they have been notified of their rights through a signed "Clients Rights and Responsibilities" and upload them into the respective charts by 4/14/23. The Clinical Supervisor will send "Clients Rights" to individuals for signature using our electronic signature software. For any individuals who are not able to, or choose not to, use the electronic signature software to sign the "Clients Right," they will have the option to either receive the packet through physical mail or come into the office to sign paper copies in person. All signed "Clients Rights," whether signed in person or electronically, will be uploaded into the respective individuals' charts by the Medical Records clerk.
All individuals in services will review and sign the "Clients Rights" at intake as part of the intake process.
When an individual enrolled in Mental Health Outpatient is identified at intake as appropriate for Drug and Alcohol services and switched into the latter service line at intake, their "Clients Rights," as part of the intake packet, will be uploaded into the Drug and Alcohol chart. The Intake Clinician responsible for switching the intake packet including signed "Client Rights" over to the new D&A Episode will alert the Clinical Supervisor that this has occurred. The Clinical Supervisor will review the new chart to ensure that the signed "Clients Rights" is present in the new chart.
Quarterly Compliance Reviews will be conducted by the Quality Assurance Department on a quarterly basis. These reviews will be attended by the Director of Operations, the Clinical Supervisor, the Clinical Director, and the Quality Assurance Manager. Quarterly Compliance Reviews will monitor the LMCMS Drug & Alcohol program's full and accurate implementation all POC items, including the presence of written acknowledgement by clients that they have been notified of their rights. The first quarterly compliance review will be conducted on 4/19/23 and every three months thereafter.
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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 a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right to request the correction of inaccurate, irrelevant, outdated, or incomplete information in their records in three of seven client records reviewed.
Client #2 was admitted on November 16. 2022 and was still active at the time of the inspection. There was no written client rights acknowledgement documented in the record at the time of the inspection.
Client #3 was admitted on August 24, 2022 and was still active at the time of the inspection. There was no written client rights acknowledgement documented in the record at the time of the inspection.
Client #4 was admitted on June 9, 2022 and was discharged on January 3, 2023. There was no written client rights acknowledgement documented in the record at the time of the inspection.
This is a repeat citation from the March 2, 2021 and February 10, 2022 annual licensing renewal inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
LMCMS Clinical Supervisor will collect written acknowledgement for charts 2 and 3 that they have been notified of their rights through a signed "Clients Rights and Responsibilities" and upload them into the respective charts by 4/14/23. The Clinical Supervisor will send "Clients Rights" to individuals for signature using our electronic signature software. For any individuals who are not able to, or choose not to, use the electronic signature software to sign the "Clients Right," they will have the option to either receive the packet through physical mail or come into the office to sign paper copies in person. All signed "Clients Rights," whether signed in person or electronically, will be uploaded into the respective individuals' charts by the Medical Records clerk.
All individuals in services will review and sign the "Clients Rights" at intake as part of the intake process.
When an individual enrolled in Mental Health Outpatient is identified at intake as appropriate for Drug and Alcohol services and switched into the latter service line at intake, their "Clients Rights," as part of the intake packet, will be uploaded into the Drug and Alcohol chart. The Intake Clinician responsible for switching the intake packet including signed "Client Rights" over to the new D&A Episode will alert the Clinical Supervisor that this has occurred. The Clinical Supervisor will review the new chart to ensure that the signed "Clients Rights" is present in the new chart.
Quarterly Compliance Reviews will be conducted by the Quality Assurance Department on a quarterly basis. These reviews will be attended by the Director of Operations, the Clinical Supervisor, the Clinical Director, and the Quality Assurance Manager. Quarterly Compliance Reviews will monitor the LMCMS Drug & Alcohol program's full and accurate implementation all POC items, including the presence of written acknowledgement by clients that they have been notified of their rights. The first quarterly compliance review will be conducted on 4/19/23 and every three months thereafter.
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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 a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right to submit rebuttal data or memoranda to their own records in three of seven client records reviewed.
Client #2 was admitted on November 16. 2022 and was still active at the time of the inspection. There was no written client rights acknowledgement documented in the record at the time of the inspection.
Client #3 was admitted on August 24, 2022 and was still active at the time of the inspection. There was no written client rights acknowledgement documented in the record at the time of the inspection.
Client #4 was admitted on June 9, 2022 and was discharged on January 3, 2023. There was no written client rights acknowledgement documented in the record at the time of the inspection.
This is a repeat citation from the March 2, 2021 and February 10, 2022 annual licensing renewal inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
LMCMS Clinical Supervisor will collect written acknowledgement for charts 2 and 3 that they have been notified of their rights through a signed "Clients Rights and Responsibilities" and upload them into the respective charts by 4/14/23. The Clinical Supervisor will send "Clients Rights" to individuals for signature using our electronic signature software. For any individuals who are not able to, or choose not to, use the electronic signature software to sign the "Clients Right," they will have the option to either receive the packet through physical mail or come into the office to sign paper copies in person. All signed "Clients Rights," whether signed in person or electronically, will be uploaded into the respective individuals' charts by the Medical Records clerk.
All individuals in services will review and sign the "Clients Rights" at intake as part of the intake process.
When an individual enrolled in Mental Health Outpatient is identified at intake as appropriate for Drug and Alcohol services and switched into the latter service line at intake, their "Clients Rights," as part of the intake packet, will be uploaded into the Drug and Alcohol chart. The Intake Clinician responsible for switching the intake packet including signed "Client Rights" over to the new D&A Episode will alert the Clinical Supervisor that this has occurred. The Clinical Supervisor will review the new chart to ensure that the signed "Clients Rights" is present in the new chart.
Quarterly Compliance Reviews will be conducted by the Quality Assurance Department on a quarterly basis. These reviews will be attended by the Director of Operations, the Clinical Supervisor, the Clinical Director, and the Quality Assurance Manager. Quarterly Compliance Reviews will monitor the LMCMS Drug & Alcohol program's full and accurate implementation all POC items, including the presence of written acknowledgement by clients that they have been notified of their rights. The first quarterly compliance review will be conducted on 4/19/23 and every three months thereafter.
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709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on a review of client records, the facility failed to document the disclosure to the client of admission, treatment, completion, and discharge during intake in three of seven client records reviewed.
Client #2 was admitted on November 16. 2022 and was still active at the time of the inspection.
Client #3 was admitted on August 24, 2022 and was still active at the time of the inspection.
Client #4 was admitted on June 9, 2022 and was discharged on January 3, 2023.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
LMCMS Clinical Supervisor will collect written acknowledgement for charts 2 and 3 that they have been disclosed the criteria for admission, treatment, completion, and discharge through a signed LMCMS Intake Packet and upload them into the respective charts by 4/14/23. The Clinical Supervisor will send Intake Packets including the disclosure to individuals for signature using our electronic signature software. For any individuals who are not able to, or choose not to, use the electronic signature software to sign the Intake Packet including the disclosure, they will have the option to either receive the packet through physical mail or come into the office to sign paper copies in person. All signed Intake Packets including the disclosure, whether signed in person or electronically, will be uploaded into the respective individuals' charts by the Medical Records clerk.
All individuals in services will review and sign the Intake Packet including the disclosure at intake as part of the intake process.
When an individual enrolled in Mental Health Outpatient is identified at intake as appropriate for Drug and Alcohol services and switched into the latter service line at intake, their the Intake Packet including the disclosure will be uploaded into the Drug and Alcohol chart. The Intake Clinician responsible for switching the intake packet including the disclosure over to the new D&A Episode will alert the Clinical Supervisor that this has occurred. The Clinical Supervisor will review the new chart to ensure that the signed Intake Packet including the disclosure is present in the new chart.
Quarterly Compliance Reviews will be conducted by the Quality Assurance Department on a quarterly basis. These reviews will be attended by the Director of Operations, the Clinical Supervisor, the Clinical Director, and the Quality Assurance Manager. Quarterly Compliance Reviews will monitor the LMCMS Drug & Alcohol program's full and accurate implementation all POC items, including the presence of the signed Intake Packet including the disclosure. The first quarterly compliance review will be conducted on 4/19/23 and every three months thereafter.
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709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
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Observations
Based on a review of client records, the facility failed to document client orientation to the project, which is to include a familiarization with project policies, during the intake and admission process in three of seven client records reviewed.
Client #2 was admitted on November 16. 2022 and was still active at the time of the inspection.
Client #3 was admitted on August 24, 2022 and was still active at the time of the inspection.
Client #4 was admitted on June 9, 2022 and was discharged on January 3, 2023.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
LMCMS Clinical Supervisor will collect written acknowledgement for charts 2 and 3 that they have been oriented to the project, including project policies, through a signed LMCMS Intake Packet and upload them into the respective charts by 4/14/23. The Clinical Supervisor will send Intake Packets including project policies to individuals for signature using our electronic signature software. For any individuals who are not able to, or choose not to, use the electronic signature software to sign the Intake Packet including project policies, they will have the option to either receive the packet through physical mail or come into the office to sign paper copies in person. All signed Intake Packets including project policies, whether signed in person or electronically, will be uploaded into the respective individuals' charts by the Medical Records clerk.
All individuals in services will review and sign the Intake Packet including project policies at intake as part of the intake process.
When an individual enrolled in Mental Health Outpatient is identified at intake as appropriate for Drug and Alcohol services and switched into the latter service line at intake, their the Intake Packet including project policies will be uploaded into the Drug and Alcohol chart. The Intake Clinician responsible for switching the intake packet including project policies over to the new D&A Episode will alert the Clinical Supervisor that this has occurred. The Clinical Supervisor will review the new chart to ensure that the signed Intake Packet including project policies is present in the new chart.
Quarterly Compliance Reviews will be conducted by the Quality Assurance Department on a quarterly basis. These reviews will be attended by the Director of Operations, the Clinical Supervisor, the Clinical Director, and the Quality Assurance Manager. Quarterly Compliance Reviews will monitor the LMCMS Drug & Alcohol program's full and accurate implementation all POC items, including the presence of the signed Intake Packet including project policies. The first quarterly compliance review will be conducted on 4/19/23 and every three months thereafter.
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709.91(b)(2)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(ii) Hours of operation.
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Observations
Based on a review of client records, the facility failed to document client orientation to the project, which is to include a familiarization with the facility's hours of operation, during the intake and admission process in three of seven client records reviewed.
Client #2 was admitted on November 16. 2022 and was still active at the time of the inspection.
Client #3 was admitted on August 24, 2022 and was still active at the time of the inspection.
Client #4 was admitted on June 9, 2022 and was discharged on January 3, 2023.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
LMCMS Clinical Supervisor will collect written acknowledgement for charts 2 and 3 that they have been oriented to the project, including hours of operation, through a signed LMCMS Intake Packet and upload them into the respective charts by 4/14/23. The Clinical Supervisor will send Intake Packets including hours of operation to individuals for signature using our electronic signature software. For any individuals who are not able to, or choose not to, use the electronic signature software to sign the Intake Packet including hours of operation, they will have the option to either receive the packet through physical mail or come into the office to sign paper copies in person. All signed Intake Packets including hours of operation, whether signed in person or electronically, will be uploaded into the respective individuals' charts by the Medical Records clerk.
All individuals in services will review and sign the Intake Packet including hours of operation at intake as part of the intake process.
When an individual enrolled in Mental Health Outpatient is identified at intake as appropriate for Drug and Alcohol services and switched into the latter service line at intake, their the Intake Packet including hours of operation will be uploaded into the Drug and Alcohol chart. The Intake Clinician responsible for switching the intake packet including hours of operation over to the new D&A Episode will alert the Clinical Supervisor that this has occurred. The Clinical Supervisor will review the new chart to ensure that the signed Intake Packet including hours of operation is present in the new chart.
Quarterly Compliance Reviews will be conducted by the Quality Assurance Department on a quarterly basis. These reviews will be attended by the Director of Operations, the Clinical Supervisor, the Clinical Director, and the Quality Assurance Manager. Quarterly Compliance Reviews will monitor the LMCMS Drug & Alcohol program's full and accurate implementation all POC items, including the presence of the signed Intake Packet including hours of operation. The first quarterly compliance review will be conducted on 4/19/23 and every three months thereafter.
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709.91(b)(2)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iii) Fee schedule.
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Observations
Based on a review of client records, the facility failed to document client orientation to the project, which is to include a familiarization with the facility's fee schedule, during the intake and admission process in three of seven client records reviewed.
Client #2 was admitted on November 16. 2022 and was still active at the time of the inspection.
Client #3 was admitted on August 24, 2022 and was still active at the time of the inspection.
Client #4 was admitted on June 9, 2022 and was discharged on January 3, 2023.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
LMCMS Clinical Supervisor will collect written acknowledgement for charts 2 and 3 that they have been oriented to the project, including the fee schedule, through a signed LMCMS Intake Packet and upload them into the respective charts by 4/14/23. The Clinical Supervisor will send Intake Packets including the fee schedule to individuals for signature using our electronic signature software. For any individuals who are not able to, or choose not to, use the electronic signature software to sign the Intake Packet including the fee schedule, they will have the option to either receive the packet through physical mail or come into the office to sign paper copies in person. All signed Intake Packets including the fee schedule, whether signed in person or electronically, will be uploaded into the respective individuals' charts by the Medical Records clerk.
All individuals in services will review and sign the Intake Packet including the fee schedule at intake as part of the intake process.
When an individual enrolled in Mental Health Outpatient is identified at intake as appropriate for Drug and Alcohol services and switched into the latter service line at intake, their the Intake Packet including the fee schedule will be uploaded into the Drug and Alcohol chart. The Intake Clinician responsible for switching the intake packet including feed schedule over to the new D&A Episode will alert the Clinical Supervisor that this has occurred. The Clinical Supervisor will review the new chart to ensure that the signed Intake Packet including the fee schedule is present in the new chart.
Quarterly Compliance Reviews will be conducted by the Quality Assurance Department on a quarterly basis. These reviews will be attended by the Director of Operations, the Clinical Supervisor, the Clinical Director, and the Quality Assurance Manager. Quarterly Compliance Reviews will monitor the LMCMS Drug & Alcohol program's full and accurate implementation all POC items, including the presence of the signed Intake Packet including the fee schedule. The first quarterly compliance review will be conducted on 4/19/23 and every three months thereafter.
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709.91(b)(2)(iv) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iv) Services provided.
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Observations
Based on a review of client records, the facility failed to document client orientation to the project, which is to include a familiarization with services provided, during the intake and admission process in three of seven client records reviewed.
Client #2 was admitted on November 16. 2022 and was still active at the time of the inspection.
Client #3 was admitted on August 24, 2022 and was still active at the time of the inspection.
Client #4 was admitted on June 9, 2022 and was discharged on January 3, 2023.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
LMCMS Clinical Supervisor will collect written acknowledgement for charts 2 and 3 that they have been oriented to the project, including services provided, through a signed LMCMS Intake Packet and upload them into the respective charts by 4/14/23. The Clinical Supervisor will send Intake Packets including services provided to individuals for signature using our electronic signature software. For any individuals who are not able to, or choose not to, use the electronic signature software to sign the Intake Packet including services provided, they will have the option to either receive the packet through physical mail or come into the office to sign paper copies in person. All signed Intake Packets including services provided, whether signed in person or electronically, will be uploaded into the respective individuals' charts by the Medical Records clerk.
All individuals in services will review and sign the Intake Packet including services provided at intake as part of the intake process.
When an individual enrolled in Mental Health Outpatient is identified at intake as appropriate for Drug and Alcohol services and switched into the latter service line at intake, their the Intake Packet including services provided will be uploaded into the Drug and Alcohol chart. The Intake Clinician responsible for switching the intake packet including services provided over to the new D&A Episode will alert the Clinical Supervisor that this has occurred. The Clinical Supervisor will review the new chart to ensure that the signed Intake Packet including services provided is present in the new chart.
Quarterly Compliance Reviews will be conducted by the Quality Assurance Department on a quarterly basis. These reviews will be attended by the Director of Operations, the Clinical Supervisor, the Clinical Director, and the Quality Assurance Manager. Quarterly Compliance Reviews will monitor the LMCMS Drug & Alcohol program's full and accurate implementation all POC items, including the presence of the signed Intake Packet including services provided. The first quarterly compliance review will be conducted on 4/19/23 and every three months thereafter.
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709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records, the facility failed to document the client's medical history, during the intake and admission process, in three of seven client records reviewed.
Client #2 was admitted on November 16. 2022 and was still active at the time of the inspection.
Client #3 was admitted on August 24, 2022 and was still active at the time of the inspection.
Client #4 was admitted on June 9, 2022 and was discharged on January 3, 2023.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
LMCMS Clinical Supervisor will collect Biopsychosocial assessments for audited charts 2 and 3, which include medical history, and upload them into the respective charts by 4/14/23.
When an individual enrolled in Mental Health Outpatient is identified at intake as appropriate for Drug and Alcohol services and switched into the latter service line at intake, their Biopsychosocial assessments, including medical history, will be uploaded into the Drug and Alcohol chart. The Intake Clinician responsible for switching the Biopsychosocial assessments including medical history over to the new D&A Episode will alert the Clinical Supervisor that this has occurred. The Clinical Supervisor will review the new chart to ensure that the Biopsychosocial assessment including medical history is present in the new chart.
Quarterly Compliance Reviews will be conducted by the Quality Assurance Department on a quarterly basis. These reviews will be attended by the Director of Operations, the Clinical Supervisor, the Clinical Director, and the Quality Assurance Manager. Quarterly Compliance Reviews will monitor the LMCMS Drug & Alcohol program's full and accurate implementation all POC items, including the presence of the Biopsychosocial assessment, including medical history. The first quarterly compliance review will be conducted on 4/19/23 and every three months thereafter.
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709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of client records, the facility failed to document the client's drug and alcohol history, during the intake and admission process, in three of seven client records reviewed.
Client #2 was admitted on November 16. 2022 and was still active at the time of the inspection.
Client #3 was admitted on August 24, 2022 and was still active at the time of the inspection.
Client #4 was admitted on June 9, 2022 and was discharged on January 3, 2023.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
LMCMS Clinical Supervisor will collect Biopsychosocial assessments for audited charts 2 and 3, which include drug or alcohol history, or both, and upload them into the respective charts by 4/14/23.
When an individual enrolled in Mental Health Outpatient is identified at intake as appropriate for Drug and Alcohol services and switched into the latter service line at intake, their Biopsychosocial assessments, including drug or alcohol history, or both, will be uploaded into the Drug and Alcohol chart. The Intake Clinician responsible for switching the Biopsychosocial assessments which includes drug or alcohol history, or both, over to the new D&A Episode will alert the Clinical Supervisor that this has occurred. The Clinical Supervisor will review the new chart to ensure that the Biopsychosocial assessment including drug or alcohol history, or both, is present in the new chart.
Quarterly Compliance Reviews will be conducted by the Quality Assurance Department on a quarterly basis. These reviews will be attended by the Director of Operations, the Clinical Supervisor, the Clinical Director, and the Quality Assurance Manager. Quarterly Compliance Reviews will monitor the LMCMS Drug & Alcohol program's full and accurate implementation all POC items, including the presence of the Biopsychosocial assessment, including drug or alcohol history, or both. The first quarterly compliance review will be conducted on 4/19/23 and every three months thereafter.
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709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records, the facility failed to document the client's personal history, during the intake and admission process, in three of seven client records reviewed.
Client #2 was admitted on November 16. 2022 and was still active at the time of the inspection.
Client #3 was admitted on August 24, 2022 and was still active at the time of the inspection.
Client #4 was admitted on June 9, 2022 and was discharged on January 3, 2023.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
LMCMS Clinical Supervisor will collect Biopsychosocial assessments for audited charts 2 and 3, which include personal history, and upload them into the respective charts by 4/14/23.
When an individual enrolled in Mental Health Outpatient is identified at intake as appropriate for Drug and Alcohol services and switched into the latter service line at intake, their Biopsychosocial assessments, including personal history, will be uploaded into the Drug and Alcohol chart. The Intake Clinician responsible for switching the Biopsychosocial assessments which include personal history, over to the new D&A Episode will alert the Clinical Supervisor that this has occurred. The Clinical Supervisor will review the new chart to ensure that the Biopsychosocial assessment including personal history, is present in the new chart.
Quarterly Compliance Reviews will be conducted by the Quality Assurance Department on a quarterly basis. These reviews will be attended by the Director of Operations, the Clinical Supervisor, the Clinical Director, and the Quality Assurance Manager. Quarterly Compliance Reviews will monitor the LMCMS Drug & Alcohol program's full and accurate implementation all POC items, including the presence of the Biopsychosocial assessment, including personal history. The first quarterly compliance review will be conducted on 4/19/23 and every three months thereafter.
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709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on a review of client records, the facility failed to document a consent to treatment, during the intake and admission process, in three of seven client records reviewed.
Client #2 was admitted on November 16. 2022 and was still active at the time of the inspection.
Client #3 was admitted on August 24, 2022 and was still active at the time of the inspection.
Client #4 was admitted on June 9, 2022 and was discharged on January 3, 2023.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
LMCMS Clinical Supervisor will collect written consent to treatment for charts 2 and 3 through a signed LMCMS Intake Packet and upload them into the respective charts by 4/14/23. The Clinical Supervisor will send Intake Packets including consent to treatment to individuals for signature using our electronic signature software. For any individuals who are not able to, or choose not to, use the electronic signature software to sign the Intake Packet including consent to treatment, they will have the option to either receive the packet through physical mail or come into the office to sign paper copies in person. All signed Intake Packets including consent to treatment, whether signed in person or electronically, will be uploaded into the respective individuals' charts by the Medical Records clerk.
All individuals in services will review and sign the Intake Packet including consent to treatment at intake as part of the intake process.
When an individual enrolled in Mental Health Outpatient is identified at intake as appropriate for Drug and Alcohol services and switched into the latter service line at intake, their the Intake Packet including consent to treatment will be uploaded into the Drug and Alcohol chart. The Intake Clinician responsible for switching the intake packet including consent to treatment over to the new D&A Episode will alert the Clinical Supervisor that this has occurred. The Clinical Supervisor will review the new chart to ensure that the signed Intake Packet including consent to treatment is present in the new chart.
Quarterly Compliance Reviews will be conducted by the Quality Assurance Department on a quarterly basis. These reviews will be attended by the Director of Operations, the Clinical Supervisor, the Clinical Director, and the Quality Assurance Manager. Quarterly Compliance Reviews will monitor the LMCMS Drug & Alcohol program's full and accurate implementation all POC items, including the presence of the signed Intake Packet including signed consent to treatment. The first quarterly compliance review will be conducted on 4/19/23 and every three months thereafter.
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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, the facility failed to document a psychosocial evaluation, during the intake and admission process, in three of seven client records reviewed.
Client #2 was admitted on November 16. 2022 and was still active at the time of the inspection.
Client #3 was admitted on August 24, 2022 and was still active at the time of the inspection.
Client #4 was admitted on June 9, 2022 and was discharged on January 3, 2023.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
LMCMS Clinical Supervisor will collect Biopsychosocial assessments for audited charts 2 and 3, which include psychosocial evaluation, and upload them into the respective charts by 4/14/23.
When an individual enrolled in Mental Health Outpatient is identified at intake as appropriate for Drug and Alcohol services and switched into the latter service line at intake, their Biopsychosocial assessments, including psychosocial evaluation, will be uploaded into the Drug and Alcohol chart. The Intake Clinician responsible for switching the Biopsychosocial assessments which include psychosocial evaluation, over to the new D&A Episode will alert the Clinical Supervisor that this has occurred. The Clinical Supervisor will review the new chart to ensure that the Biopsychosocial assessment including psychosocial evaluation, is present in the new chart.
Quarterly Compliance Reviews will be conducted by the Quality Assurance Department on a quarterly basis. These reviews will be attended by the Director of Operations, the Clinical Supervisor, the Clinical Director, and the Quality Assurance Manager. Quarterly Compliance Reviews will monitor the LMCMS Drug & Alcohol program's full and accurate implementation all POC items, including the presence of the Biopsychosocial assessment, including psychosocial evaluation. The first quarterly compliance review will be conducted on 4/19/23 and every three months thereafter.
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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 patient records, the facility failed to comply with plans of correction that were approved by the Department.
Plans of correction documenting that the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information were submitted and approved by the Department for the March 2, 2021 and February 10, 2022 annual licensing inspections. Failing to obtain an informed and voluntary consent from the client for the disclosure of information was again found to be a deficiency in the February 13, 2023 licensing inspection.
Plans of correction documenting that the facility will inform all clients of their regulatory client rights were submitted and approved by the Department for the March 2, 2021 and February 10, 2022 annual licensing inspections. Failing to document that clients were informed of their regulatory client rights was again found to be a deficiency in the February 13, 2023 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Quarterly Compliance Reviews will be conducted by the Quality Assurance Department on a quarterly basis. These reviews will be attended by the Director of Operations, the Clinical Supervisor, the Clinical Director, and the Quality Assurance Manager. Quarterly Compliance Reviews will monitor the LMCMS Drug & Alcohol program's full and accurate implementation all POC items. The first quarterly compliance review will be conducted on 4/19/23 and every three months thereafter. Minutes and results of Quarterly Compliance Reviews will be documented by the Quality Assurance Manager and will submitted to the Facility Director. |