INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 5, 2019 through December 6, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Crisis Management Services, 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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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
The facility failed to follow the project's written procedures for the management of treatment/rehabilitation services by failing to complete a comprehensive treatment plan within 72 hours of admission, per facility policy, in five of seven client records.
Client #1 was admitted on October 18, 2019 and still active at the time of the inspection. The comprehensive treatment plan was to be completed no later than October 21, 2019; however, the plan wasn't completed until October 28, 2019.
Client #2 was admitted on October 24, 2019 and still active at the time of the inspection. The comprehensive treatment plan was to be completed no later than October 27, 2019; however, the plan wasn't completed until October 28, 2019.
Client #3 was admitted on November 9, 2019 and still active at the time of the inspection. The comprehensive treatment plan was to be completed no later than November 12, 2019; however, the plan wasn't completed until November 18, 2019.
Client #4 was admitted on January 8, 2019 and was discharged on February 28, 2019. The comprehensive treatment plan was to be completed no later than January 11, 2019; however, the plan wasn't completed until January 14, 2019.
Client #6 was admitted on February 27, 2019 and was discharged on April 12, 2019. The comprehensive treatment plan was to be completed no later than March 2, 2019; however, the plan wasn't completed until March 6, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director or Facility Director will revise the written policy for comprehensive treatment plans. The revised time period will allow time for clinicians to complete a thorough assessment of the client's needs and goals. The revised treatment plan policy will be reviewed with all staff by the Project Director or Facility Director by 1/20/2020 and implemented on 1/21/2020. The Project or Facility Director will randomly review clients' charts to ensure that all treatment plans are developed according to the project's policy. |
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
The facility failed to document the purpose of disclosure on release of information forms in one of seven client records reviewed.
Client #3 was admitted on November 9, 2019 and was still active at the time of the inspection. A consent to release information form to another treatment facility was signed and dated on November 13, 2019.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director or Facility Director will review the release of information form with all staff members and discuss each element and its purpose by 1/20/20. The chart sited is an active chart that was corrected with client on 12/9/2019. Releases of information will be randomly reviewed by the Facility Director or Project Director on a monthly basis to ensure that all proper elements are documented accurately.
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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
The facility failed to document, in writing, that clients were informed that they may not be discriminated upon in the provision of services based on race or creed in every client record reviewed.
Client #1 was admitted on October 18, 2019 and was active at the time of the inspection.
Client #2 was admitted on October 24, 2019 and was active at the time of the inspection.
Client #3 was admitted on November 9, 2019 and was active at the time of the inspection.
Client #4 was admitted on January 8, 2019 and was discharged on February 28, 2019.
Client #5 was admitted on January 2, 2019 and was discharged on March 1, 2019.
Client #6 was admitted on February 27, 2019 and was discharged on April 12, 2019.
Client #7 was admitted on April 16, 2019 and was discharged on May 29, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project will revise and include race and creed to the client's rights form that is reviewed and signed by the client and admitting staff member. The revised client's rights form will be implemented for all new admissions. Addiction counselors will review the revised patient right's form with their active clients by 12/20/19. The revised signed form will be placed into the client's active record. Facility or project director will ensure all active records have been updated by the end of the business day on 12/20/19.Monthly random reviews will be conducted by the projector or facility director to ensure that all proper elements are included on the client's rights form. |