INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 5, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Arkview Recovery 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:
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Plan of Correction
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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 one of twenty-six client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the specific information disclosed.
Client #10 was admitted on May 26, 2023and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated June 2, 2023 to a treatment facility did not provide the specific information that was to be disclosed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director and Compliance Coordinator met to identify why this deficiency was occurring. It was determined that staff training was the main component for the cause of the deficiency. As a result, all staff were trained on the proper completion of a release of information form, including ensuring to provide the specific information that is to be disclosed.
To prevent the deficiency from recurring, the Compliance Coordinator has added the review of Release of Information to the Clinical Chart Audit Tool, where a random sampling of 20% of active charts are reviewed on a monthly basis to ensure ongoing compliance. |
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 five of twenty-six client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the purpose of the disclosure
Client # 1 was admitted on May 31, 2023 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated May 31, 2023 to an emergency contact did not include the purpose of the disclosure.
Client # 7 was admitted on May 10, 2023 and was discharged on May 18, 2023. An informed and voluntary consent from the client for the disclosure of information dated May 9, 2023 to an emergency contact did not include the purpose of the disclosure.
Client # 8 was admitted on April 29, 2023 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated May 25, 2023 to an outside agency did not include the purpose of the disclosure.
Client # 11 was admitted on May 15, 2023 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated May 22, 2023 to the funding source did not include the purpose of the disclosure.
Client # 18 was admitted on April 25, 2023 and was discharged on May 31, 2023. An informed and voluntary consent from the client for the disclosure of information dated May 25, 2023 to an outside provider did not include the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director and Compliance Coordinator met to identify why this deficiency was occurring. It was determined that staff training was the main component for the cause of the deficiency. As a result, all staff were trained on the proper completion of a release of information form, including ensuring to include the purpose of the disclosure.
To prevent the deficiency from recurring, the Compliance Coordinator has added the review of Release of Information to the Clinical Chart Audit Tool, where a random sampling of 20% of active charts are reviewed on a monthly basis to ensure ongoing compliance. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on the review of client records, the facility failed to document a completed consent to release information form in all twenty-six client records reviewed, as all the forms did not include a copy of the consent was offered to the client.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Executive Director and Compliance Coordinator met to identify why this deficiency was occurring. It was identified that the EMR template for the consent to release information form needed to be revised to include the statement that "a copy of the consent was offered to the client". The Compliance Coordinator has made the necessary changes to the EMR template and it now includes the missing statement.
Staff responsible for completing consent to release information forms were all trained via staff meeting and memo's on the changes made, specifically the requirement that a copy of the consent must be offered to the client.
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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 notify clients that they shall retain civil rights and liberties except as provided by statue and no client may be deprived of a civil right solely by reason of treatment in all twenty-six records reviewed
This finding was reviewed with facility staff during the licensing inspection.
This is a repeat citation from the June 9, 2022 inspection.
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Plan of Correction
The Executive Director and Compliance Coordinator met to identify why this deficiency was occurring. It was identified that the EMR template for the Client Rights form needed to be revised to include the statement notifying the Client that "All Clients shall retain civil rights and liberties except as provided by statue and no client may be deprived of a civil right solely by reason of treatment". The Compliance Coordinator has made the necessary changes to the EMR template and it now includes the missing statement.
Staff responsible for completing Client Rights forms were all trained via staff meeting and memo's on the changes made, specifically the requirement to notify Clients that "All Clients shall retain civil rights and liberties except as provided by statue and no client may be deprived of a civil right solely by reason of treatment". |
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 notify clients that they may not be discriminated against based on ethnicity, marital status, sexual orientation, handicap, or religion in all twenty-six records reviewed.
This finding was reviewed with facility staff during the licensing inspection.
This is a repeat citation from the June 9, 2022 inspection.
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Plan of Correction
The Executive Director and Compliance Coordinator met to identify why this deficiency was occurring. It was identified that the EMR template for the Client Rights form needed to be revised to include the statement notifying the Client that "they may not be discriminated against based on ethnicity, marital status, sexual orientation, handicap, or religion". The Compliance Coordinator has made the necessary changes to the EMR template and it now includes the missing statement.
Staff responsible for completing Client Rights forms were all trained via staff meeting and memo's on the changes made, specifically the requirement to notify Clients that ""they may not be discriminated against based on ethnicity, marital status, sexual orientation, handicap, or religion". |
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 notify clients that the director may temporarily remove portions of their record prior to the inspection by the client and reasons for removing sections shall be documented in all twenty-six records reviewed .
This finding was reviewed with facility staff during the licensing inspection.
This is a repeat citation from the June 9, 2022 inspection
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Plan of Correction
The Executive Director and Compliance Coordinator met to identify why this deficiency was occurring. It was identified that the EMR template for the Client Rights form needed to be revised to include the statement notifying the Client that "the Director may temporarily remove portions of their record prior to the inspection by the client and reasons for removing sections shall be documented". The Compliance Coordinator has made the necessary changes to the EMR template and it now includes the missing statement.
Staff responsible for completing Client Rights forms were all trained via staff meeting and memo's on the changes made, specifically the requirement to notify Clients that ""the Director may temporarily remove portions of their record prior to the inspection by the client and reasons for removing sections shall be documented". |
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 notify clients that they have the right to appeal a decision limiting access to their records in all twenty six records reviewed.
This finding was reviewed with facility staff during the licensing inspection.
This is a repeat citation from the June 9, 2022 inspection
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Plan of Correction
The Executive Director and Compliance Coordinator met to identify why this deficiency was occurring. It was identified that the EMR template for the Client Rights form needed to be revised to include the statement notifying the Client that "they have the right to appeal a decision limiting access to their records". The Compliance Coordinator has made the necessary changes to the EMR template and it now includes the missing statement.
Staff responsible for completing Client Rights forms were all trained via staff meeting and memo's on the changes made, specifically the requirement to notify Clients that "they have the right to appeal a decision limiting access to their records". |
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 notify clients that they have the right to request correction of inaccurate, irrelevant, outdated or incomplete information in their records in all twenty six records reviewed.
This finding was reviewed with facility staff during the licensing inspection.
This is a repeat citation from the June 9, 2022 inspection
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Plan of Correction
The Executive Director and Compliance Coordinator met to identify why this deficiency was occurring. It was identified that the EMR template for the Client Rights form needed to be revised to include the statement notifying the Client that "they have the right to request correction of inaccurate, irrelevant, outdated or incomplete information in their records". The Compliance Coordinator has made the necessary changes to the EMR template and it now includes the missing statement.
Staff responsible for completing Client Rights forms were all trained via staff meeting and memo's on the changes made, specifically the requirement to notify Clients that "they have the right to request correction of inaccurate, irrelevant, outdated or incomplete information in their records". |
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 notify clients that they have the right to submit rebuttal data or memoranda to their record in all twenty six records reviewed .
This finding was reviewed with facility staff during the licensing inspection.
This is a repeat citation from the June 9, 2022 inspection
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Plan of Correction
The Executive Director and Compliance Coordinator met to identify why this deficiency was occurring. It was identified that the EMR template for the Client Rights form needed to be revised to include the statement notifying the Client that "they have the right to submit rebuttal data or memoranda to their record". The Compliance Coordinator has made the necessary changes to the EMR template and it now includes the missing statement.
Staff responsible for completing Client Rights forms were all trained via staff meeting and memo's on the changes made, specifically the requirement to notify Clients that "they have the right to submit rebuttal data or memoranda to their record". |
709.82(a)(2) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on five of five partial hospitalization client records reviewed, the facility failed to provide an individual treatment and rehabilitation plan developed with the client to include the type of treatment and rehabilitation services.
Client #15 was admitted on May 22, 2023 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on May 22, 2023; however, there was no documentation of type of services.
Client #16 was admitted on April 14, 2023 and was discharged on May 20, 2023. A comprehensive treatment and rehabilitation plan was developed with the client on Aril 21, 2023; however, there was no documentation of type of services
Client #17 was admitted on December 26, 2022 and was discharged on January 31, 2023. A comprehensive treatment and rehabilitation plan was developed with the client on January 2, 2023; however, there was no documentation of type of services
Client #18 was admitted on April 25, 2023 and was discharged on May 31, 2023. A comprehensive treatment and rehabilitation plan was developed with the client on May 4, 2023; however, there was no documentation of type of services
Client #19 was admitted on April 1, 2023 and discharged on May 1, 2023. A comprehensive treatment and rehabilitation plan was developed with the client on April 3, 2023; however, there was no documentation of type of services
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director and Compliance Coordinator met to identify why this deficiency was occurring. It was identified that as a QA Committee, the standard was misinterpreted. Thus were documenting within the treatment plan the type of treatment and rehabilitation services as the level of care (Detox, RTC, PHP, IOP with the corresponding schedule) versus the standards interpretation education our team received during the on-site. Which clarified that the type of treatment and rehabilitation services the regulations require are specific to individual sessions and group sessions with frequencies of each type of session documented. To correct the deficiency, the Compliance Coordinator has made the necessary changes to the EMR template which now prompts the Qualified Professional developing comprehensive treatment and rehabilitation plan with the client, to document the frequencies and planned schedule of individual and group sessions required.
The Qualified Professionals responsible for completing treatment plans were all trained via staff meetings and memo's on the changes made. Specifically the requirement to document within the treatment plan the frequencies and planned schedule of individual and group sessions required and developed with the client.
Additionally, the policies for Treatment Planning have been revised to include the revised language stating that the comprehensive treatment and rehabilitation plan, developed with the client, shall document the frequencies and planned schedule of individual and group sessions required the individual. All pertinent staff were trained on the revised policies and provided a copy. |
709.63(a)(7) LICENSURE Discharge summary
709.63. 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:
(7) Discharge summary.
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Observations
Based on one of three applicable detox client records reviewed, the facility failed to provide a discharge summary in accordance with the facility policy and procedure manual. The policy and procedure manual indicates a discharge summary be completed within 72 hours of discharge.
Client # 5 was admitted on May 1, 2023 and was discharged on May 4, 2023,. The discharge summary was due to be completed no later than May 9th, 2023; however, the discharge summary was not completed.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the June 9, 2022 inspection
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Plan of Correction
The Executive Director and Compliance Coordinator met to identify why this deficiency was occurring. It was determined that staff training was the main component for the cause of the deficiency. As a result, all staff were trained on the agency policies for completion of Discharge Summaries, specifically that they are required to be completed within 72 hours of discharge.
To prevent the deficiency from recurring, the Compliance Coordinator has added the review of completion of Discharge Summaries per agency policy, to the Clinical Chart Audit Tool, where a random sampling of 20% of active charts are reviewed on a monthly basis to ensure ongoing compliance. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on seven of seven inpatient client records reviewed, the facility failed to provide an individual treatment and rehabilitation plan developed with the client to include the type of treatment and rehabilitation services.
Client #8 was admitted on April 29, 2023 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on May 25, 2023; however, there was no documentation of type of services.
Client #9 was admitted on May 12, 2023 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on May 18, 2023; however, there was no documentation of type of services.
Client #10 was admitted on May 26, 2023 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on May 26, 2023; however, there was no documentation of type of services.
Client #11 was admitted on May 15, 2023 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on May 25, 2023; however, there was no documentation of type of services.
Client #12 was admitted on April 21, 2023 and discharged on May 2, 2023. A comprehensive treatment and rehabilitation plan was developed with the client on April 26, 2023; however, there was no documentation of type of services.
Client #13 was admitted on March 21, 2023 and discharged on May 9, 2023. A comprehensive treatment and rehabilitation plan was developed with the client on March 24, 2023; however, there was no documentation of type of services.
Client #14 was admitted on April 20, 2023 and discharged on May 1, 2023. A comprehensive treatment and rehabilitation plan was developed with the client on April 27, 2023; however, there was no documentation of type of services
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director and Compliance Coordinator met to identify why this deficiency was occurring. It was identified that as a QA Committee, the standard was misinterpreted. Thus were documenting within the treatment plan the type of treatment and rehabilitation services as the level of care (Detox, RTC, PHP, IOP with the corresponding schedule) versus the standards interpretation education our team received during the on-site. Which clarified that the type of treatment and rehabilitation services the regulations require are specific to individual sessions and group sessions with frequencies of each type of session documented. To correct the deficiency, the Compliance Coordinator has made the necessary changes to the EMR template which now prompts the Qualified Professional developing comprehensive treatment and rehabilitation plan with the client, to document the frequencies and planned schedule of individual and group sessions required.
The Qualified Professionals responsible for completing treatment plans were all trained via staff meetings and memo's on the changes made. Specifically the requirement to document within the treatment plan the frequencies and planned schedule of individual and group sessions required and developed with the client.
Additionally, the policies for Treatment Planning have been revised to include the revised language stating that the comprehensive treatment and rehabilitation plan, developed with the client, shall document the frequencies and planned schedule of individual and group sessions required the individual. All pertinent staff were trained on the revised policies and provided a copy. |
709.53(a)(10) LICENSURE Discharge Summary
709.53. 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:
(10) Discharge summary.
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Observations
Based on two of three applicable inpatient client records reviewed, the facility failed to provide a discharge summary in accordance with the facility policy and procedure manual. The policy and procedure manual indicates a discharge summary be completed within 72 hours of discharge.
Client # 12 was admitted on April 21, 2023 and was discharged on May 2, 2023,. The discharge summary was due to be completed no later than May 5th, 2023; however, the discharge summary was not completed.
Client # 14 was admitted on April 20, 2023 and was discharged on May 1, 2023. The discharge summary was due to be completed no later than May 4, 2023; however, the discharge summary was not completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director and Compliance Coordinator met to identify why this deficiency was occurring. It was determined that staff training was the main component for the cause of the deficiency. As a result, all staff were trained on the agency policies for completion of Discharge Summaries, specifically that they are required to be completed within 72 hours of discharge.
To prevent the deficiency from recurring, the Compliance Coordinator has added the review of completion of Discharge Summaries per agency policy, to the Clinical Chart Audit Tool, where a random sampling of 20% of active charts are reviewed on a monthly basis to ensure ongoing compliance. |