INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 2, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Visualize Change, 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) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on the review of seven client records, the facility failed to document a completed consent to release information form in one out of seven records reviewed.
Client #3 was admitted on October 4, 2023 and was still active at the time of the inspection. A consent form dated October 4, 2023 to the emergency contact did not contain the purpose of the release.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Counselors will be trained by the facility director by 1/30/24 that a reason for the consent to release of information must be indicated on all release forms. The facility director will audit all new intakes to make sure the reason for the release of information is indicated. |
709.34 (c) (2) 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:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Based on a conversation with the project director, the facility failed to inform the Department of an unusual incident within the required three days. It was discovered that the facility had an unusual incident occur on December 2, 2023, which involved the death of the client. Upon further inspection, it was discovered that the facility had not submitted a written unusual incident report to the Department within the regulatory three business day timeframe.
These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
The Facility Director is responsible for reporting of Unusual Incidents. The facility director will review the Unusual Incident policy yearly to ensure the proper procedure is followed. Any Unusual Incidents will be reported within 48 hours of the occurrence of the incident. The incident in question has been reported at this time. |
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 document treatment plan updates within the regulatory timeframe in three out of four applicable client records reviewed.
Client #1 was admitted on June 12, 2023 and was still active at the time of the inspection. A treatment plan update was completed on July 11, 2023 and the next update was due no later than September 11, 2023; however, the next update was completed on November 12, 2023.
Client #4 was admitted on November 21, 2022 and was still active at the time of the inspection. A treatment plan update was completed on October 3, 2023 and the next update was due no later than December 3, 2023; however, it was completed on December 13, 2023.
Client #6 was admitted on June 8, 2022 and discharged on December 28, 2023. A treatment plan update was completed on August 23, 2023 and the next update was due no later than October 23, 2023; however, it was completed on November 12, 2023.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Counselors will be informed and trained by 1/30/2024 that the treatment plan updates must be done every 60 days and the Master treatment plan must be done 30 days after the Preliminary Treatment Plan. the facility director is responsible for this training. The facility director will audit random files quarterly to ensure the treatment plans are being updated at the appropriate times. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in four of seven client records reviewed.
Client #1 was admitted on June 12, 2023 and was still active at the time of the inspection. The treatment plan dated July 11, 2023 indicated one individual session weekly. There was no documentation of the client receiving individual session from September 12, 2023 through October 8, 2023. In addition, there was no documentation that the client received individual sessions weekly between November 27, 2023 through December 18, 2023.
Client #3 was admitted October 4, 2023 and was still active at the time of the inspection. The treatment plan dated November 15, 2023 indicated weekly individual sessions. There was no documentation that the client received individual sessions between October 13, 2023 and November 15, 2023. In addition, there was no documentation that the client received any individual sessions since November 22, 2023.
Client #6 was admitted on June 8, 2022 and was discharged on December 28, 2023. The treatment plan dated August 23, 2023 indicated individual and group sessions weekly. There was no documentation that the client received group sessions since September 3, 2023.
Client #7 was admitted on July 19, 2023 and was discharge on October 31, 2023. The treatment plan dated September 7, 2023 indicated individual weekly sessions. There was no documentation that the client received individual session from September 13, 2023 through October 2, 2023.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Counselors will be trained in documentation of correspondence with the clients and to note that in the client record by 1/30/2024. If an appt is missed there must be a record of why the appt was missed. If none was scheduled, there should be a record of outreach to the client as to show why no appt was scheduled.the facility director will audit random charts quarterly to ensure this policy is being followed. |
709.93(a)(9) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to document a aftercare plan in three out of three applicable records reviewed.
Client #5 was admitted on August 31, 2023 and was discharged on November 15, 2023. No aftercare plan was documented in the client record at the time of the discharge.
Client #6 was admitted on on June 8, 2022 and was discharged on December 28, 2023. No aftercare plan was documented in the client record at the time of the inspection.
Client #7 was admitted on July 19, 2023 and was discharged on October 31, 2023. No aftercare plan was documented in the client record at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
the facility directors will rewrite the Aftercare plan policy to reflect that only clients that are discharged successfully will be afforded an aftercare plan. When a client is successfully discharged they will be given an aftercare plan that they go over with their counselor. the facility director will audit all successful discharges to ensure that an aftercare plan is in place. |