INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on January 26, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Care Center dba SPHS Care Center 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of the client records, the facility failed to document written acknowledgement by the clients that they have been notified of those rights specifically that the project may not discriminate on the basis of age in seven out of seven client records reviewed.These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
The Client Orientation Packet provided to every client at the time of their initial evaluation was amended by the Clinical Director on 1/26/2022 to include the approved nondiscriminatory policy wording, "Our Program will not deny service to any client based on age, ethnicity, race, color, sexual orientation, or national origin, marital status, sex, handicap, or religion/creed. The Program will follow all Federal, State, and Local laws concerning Program services." All new clients will electronically sign an Orientation Packet Checklist in Credible indicating that they received a copy of said packet and Non-Discrimination policy. All previous copies of the orientation packet have been removed from the facility. A digital copy was also sent to all staff to offer to current clients who may have received the previous version. |
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.
|
Observations
Based on a review of the client records, the facility failed to document that client orientation had taken place in three out of seven client records reviewed. Client #2 was admitted on November 18, 2021 and was still active at the time of the inspection. Client #3 was admitted on November 22, 2021 and was still active at the time of the inspection. Client #5 was admitted on September 21, 2021 and was discharged on December 28, 2021. The findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
The process for intake/assessment and readmission was reviewed and updated following the exit survey on 1/26/22. Form groups within the EHR have been established to ensure pertinent intake forms are reviewed and completed. Program staff were retrained on the assessment process on 1/31/2022. Compliance with this process and confirmation of orientation information being reviewed with clients will be ensured during ongoing chart reviews by the individual staff as well as the clinical supervisor. Current charts will reflect required documentation no later than 3/31/22. |
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.
|
Observations
Based on a review of client records, the facility failed to ensure that medical histories were obtained in three out of seven client records reviewed. Client #2 was admitted on November 18, 2021 and was still active at the time of the inspection. Client #5 was admitted on September 21, 2021 and was discharged on December 28, 2021.Client # 6 was admitted on July 20, 2021 and discharged on October 14, 2021.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The process for intake/assessment and readmission was reviewed and updated following the exit survey on 1/26/22. Program staff were retrained on the assessment process on 1/31/2022 which included the required documentation of a client's medical history as well as documentation for any updates to such when a person is readmitted into treatment. Compliance with this process and confirmation of orientation information being reviewed with clients will be ensured during ongoing chart reviews by the individual staff as well as the clinical supervisor. Current charts will reflect required documentation no later than 3/31/22. |
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.
|
Observations
Based on a review of client records, the facility failed to ensure that drug or alcohol histories were obtained in three out of seven client records reviewed. Client #2 was admitted on November 18, 2021 and was still active at the time of the inspection. Client #5 was admitted on September 21, 2021 and was discharged on December 28, 2021.Client # 6 was admitted on July 20, 2021 and discharged on October 14, 2021.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The process for intake/assessment and readmission was reviewed and updated following the exit survey on 1/26/22. Program staff were retrained on the assessment process on 1/31/2022 which included the required documentation of a client's drug and alcohol history as well as documentation for any updates to such when a person is readmitted into treatment. Compliance with this process and confirmation of orientation information being reviewed with clients will be ensured during ongoing chart reviews by the individual staff as well as the clinical supervisor. Current charts will reflect required documentation no later than 3/31/22. |
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.
|
Observations
Based on a review of client records, the facility failed to ensure that personal histories were obtained in three out of seven client records reviewed. Client #2 was admitted on November 18, 2021 and was still active at the time of the inspection. Client #5 was admitted on September 21, 2021 and was discharged on December 28, 2021.Client # 6 was admitted on July 20, 2021 and discharged on October 14, 2021.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The process for intake/assessment and readmission was reviewed and updated following the exit survey on 1/26/22. Program staff were retrained on the assessment process on 1/31/2022 which included the required documentation of a client's personal history as well as documentation for any updates to such when a person is readmitted into treatment. Compliance with this process and confirmation of orientation information being reviewed with clients will be ensured during ongoing chart reviews by the individual staff as well as the clinical supervisor. Current charts will reflect required documentation no later than 3/31/22. |