INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 17, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Holcomb Associates, 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
Based on review of client records, the facility failed to follow the project's written procedures for the management of treatment/rehabilitation services for four of seven client records reviewed.
Client # 2 was admitted on April 13, 2021 and was active at time of inspection. The written procedure in the policy manual stated that preliminary treatment plans will be completed on the day of admission, however; the initial treatment plan was completed on April 29, 2021.
Client # 3 was admitted on March 29, 2021 and was active at time of inspection. The written procedure in the policy manual stated that preliminary treatment plans will be completed on the day of admission, however; the initial treatment plan was completed on May 5, 2021. Additionally, the written procedure in the policy manual stated that master treatment plans will be completed within 30 days of admission; however, the master treatment plan was not completed at the time of inspection.
Client # 5 was admitted on January 7, 2020 and discharged on March 31, 2020. The written procedure in the policy manual stated that preliminary treatment plans will be completed on the day of admission, however; the initial treatment plan was completed on January 17, 2020.
Client # 6 was admitted on February 18, 2020 and discharged on March 13, 2020. The written procedure in the policy manual stated that preliminary treatment plans will be completed on the day of admission, however; the initial treatment plan was completed on February 21, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clinical staff will be re-trained by clinical supervisor on the requisite deadlines and timeliness of completing both preliminary and master treatment plans, both as a group as well as at least quarterly follow up in individual supervisions. Group training will be completed by June 30th, 2021. This will be documented in a group supervision note.
Clinical supervisor will develop and utilize a client chart documentation spreadsheet to ensure timely completion of both preliminary and master treatment plans. This process will be in place by June 30th, 2021.
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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 a written informed and voluntary consent form prior to the disclosure of information in one of seven client records reviewed.
Client # 1 was admitted on April 15, 2021 and was still active at the time of inspection. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no valid consent to release information form signed by the client documented in the record prior to the disclosures.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clinical staff will be re-trained by clinical supervisor on 28 Pa Code 709.28 regulations relating to informed and voluntary consent related to disclosure of client information by June 30th, 2021. This will be documented in a group supervision note.
Client #1 was discharged from the program prior to receipt of this observation ? thus, an ROI will not be able to be obtained.
Clinical supervisor will develop and utilize a client chart documentation spreadsheet to check all client releases of information for compliance. This process will be in place by June 30th, 2021.
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709.28 (c) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to keep consent to release information forms within the limits established by 4 Pa. Code 255.5 (b) for releases of information in five of seven client records reviewed.
Client # 2 was admitted on April 13, 2021 and was active at time of inspection. A release of information form to a government agency was signed and dated by the client on May 7, 2021 and allowed for the release of diagnostic evaluations, chemical dependency evaluation, psychological evaluation, psychiatric evaluation, biopsychosocial evaluation, psychiatric/neuropsychiatric testing, treatment plans, behavior management plan, plan of care, discharge/aftercare plan, ISPT/ITM packet, treatment summary, discharge summary, IEP/529 plan, court records, and health records, all of which exceeds the limits established by 4 Pa. Code 255.5. Additionally, release of information forms to an insurance provider, emergency contact, and primary care physician were all signed and dated by the client on April 22, 2021, but none of the forms documented the specific information to be disclosed.
Client # 3 was admitted on March 29, 2021 and was active at time of inspection. A release of information form to an insurance provider was signed and dated by the client on April 7, 2021 and allowed for the release of diagnostic evaluations, chemical dependency evaluation, psychological evaluation, psychiatric evaluation, biopsychosocial evaluation, psychiatric/neuropsychiatric testing, treatment plans, behavior management plan, plan of care, discharge/aftercare plan, ISPT/ITM packet, treatment summary, discharge summary, IEP/529 plan, court records, and health records, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client # 4 was admitted on September 3, 2019 and was discharged on September 16, 2019. A release of information form to an insurance provider was signed and dated by the client on August 5, 2019 and allowed for the release of diagnostic evaluations, psychiatric evaluation, treatment plans, plan of care, discharge/aftercare plan, treatment summary, and discharge summary, all of which exceeds the limits established by 4 Pa. Code 255.5. Additionally, a release of information form to a government agency was signed and dated by the client on September 4, 2019 and allowed for the release of diagnostic evaluations, psychiatric evaluation, discharge/aftercare plan, and treatment summary, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client # 6 was admitted on February 18, 2020 and discharged on March 13, 2020. A release of information form to a primary care physician was signed and dated by the client on February 21, 2021, but did not document the specific information to be disclosed.
Client # 7 was admitted on August 22, 2019 and discharged on September 13, 2019. A release of information form to an insurance provider was signed and dated by the client on August 22, 2019 and allowed for the release of psychological evaluations, psychiatric evaluations, treatment plans, discharge/aftercare plans, and discharge summary, all of which exceeds the limits established by 4 Pa. Code 255.5.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clinical staff will be re-trained by clinical supervisor on 28 Pa Code 709.28 regulations (including 4 Pa Code 255.5) relating to informed and voluntary consent related to disclosure of client information by June 30th, 2021. This will be documented in a group supervision note.
Existing releases of information for clients 2 and 3 that are out of compliance with 4 Pa Code 255.5 will be revoked immediately by clinical supervisor and these clients will be given the opportunity at their next appointment to sign updated and fully compliant releases that specify the information to be released.
Clinical coordinator will utilize a regularly updated chart documentation spreadsheet to check all client releases of information for compliance. This process will be in place by June 30th, 2021.
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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 a review of client records, the facility failed to document the purpose of a disclosure on consent forms in one of seven client records reviewed.
Client # 6 was admitted on February 18, 2020 and discharged on March 13, 2020. A release of information form to a primary care physician was signed and dated by the client on February 21, 2020 and did not document the purpose of disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clinical staff will be re-trained by clinical supervisor on 28 Pa Code 709.28 regulations relating to informed and voluntary consent related to disclosure of client information by June 30th, 2021. This will be documented in a group supervision note.
Clinical coordinator will utilize a regularly updated chart documentation spreadsheet to check all client releases of information for compliance. This process will be in place by June 30th, 2021.
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709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to provide and inform clients of an opportunity to request reconsideration of a decision terminating treatment in two of four applicable client records reviewed.
Client # 5 was admitted on January 7, 2020 and discharged on March 31, 2020. The termination letter did not provide the client an opportunity to request reconsideration termination of treatment.
Client # 6 was admitted on February 18, 2020 and discharged on March 13, 2020. The termination letter did not provide the client an opportunity to request reconsideration termination of treatment.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clinical staff will be re-trained by clinical supervisor by June 30th, 2021 on 28 Pa Code 709.33(b) regulations that clients must be offered in writing an opportunity to request reconsideration of a decision terminating treatment. This will be documented in a group supervision note.
Clinical coordinator will consult at least monthly with clinical staff in individual supervisions about clients who may be at risk of involuntary termination of treatment and ensure letters sent to these clients include a notification that clients may request reconsideration of a decision terminating treatment.
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709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record, which is to include follow-up information, in two of four applicable client records reviewed.
Client # 5 was admitted on January 7, 2020 and discharged on March 31, 2020. There was no documentation of follow-up in the client record at the time of the inspection.
Client # 6 was admitted on February 18, 2020 and discharged on March 13, 2020. There was no documentation of follow-up in the client record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clinical staff will be re-trained by clinical supervisor by June 30th, 2021 on 28 Pa Code 709.93 and internal regulations that require documented follow up attempts to clients. This will be documented in a group supervision note.
Clinical coordinator will follow up with clinical staff post-discharge for all clients to ensure proper follow up attempts were completed and documented. This will be tracked using a chart documentation spreadsheet. This process will be in place by June 30th, 2021.
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