INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 28, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Newvitae 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) 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
The facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in three of nine client records reviewed.
Client #1 was admitted in the outpatient program on August 11, 2017 and was still active at the time of the inspection. The consent to release information form to the funding source, signed by client on June 7, 2018, allowed for the release of the psychiatric evaluation, the treatment plan, the discharge summary, the aftercare plan, and medications/lab results/UDS results, which exceeded 4 PA code 255.5.
Client #2 was admitted in the outpatient program on March 7, 2018 and was still active at the time of the inspection. The consent to release information form to the funding source, signed by client on April 9, 2018, allowed for the release of the psychiatric evaluation, the treatment plan, the discharge summary, the aftercare plan, and medications/lab results/UDS results, which exceeded 4 PA code 255.5.
Client #8 was admitted in the partial hospitalization program on June 26, 2018 and was discharged on July 10, 2018. The consent to release information form to the funding source, signed by client on June 26, 2018, allowed for the release of the psychiatric evaluation, the treatment plan, the discharge summary, the aftercare plan, and medications/lab results/UDS results, which exceeded 4 PA code 255.5.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1) Meet with all staff members and review the proper use of the "other" section on a release form. COMPLETED 11/29/18
2)Educate all staff about the DDAP regulations regarding confidentiality and regularly run reports from our new EHR to ensure the ROI's are completed according to DDAP standards.
3)Clients #1 is an active client at the time of this CAP. His ROI to his funding source was removed from his chart today, 12/4/18. The office assistant will have him sign a ROI for his funding source when he comes to his next appointment which is scheduled for 12/12/18.
4)Client #2 is an active client at the time of this CAP. Her ROI to her funding source was removed from her chart today, 12/4/18. The office assistant will have her sign a ROI for her funding source when she comes to her next appointment which is scheduled for 12/12/18.
5) Client #8-- has been discharged from our program since July 10, 2018. |
709.81(b)(1) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
The facility failed to provide intake documentation verifying that the criteria for admission, treatment, completion, and discharge was disclosed to the client in two of four client records reviewed.
Client #8 was admitted on June 26, 2018 and was discharged on July 10, 2018.
Client #9 was admitted on January 23, 2018 and was discharged on March 23, 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will educate all staff and inform them that we will begin using a form that was utilized in the past that clearly documents the criteria for admission, treatment, completion, and discharge. This has been completed effective 11/29/18.
When the program moved this past year, some how we missed utilizing this form.
Further, the clinical supervisor will ensure that the form will be added into our new EHR to help ensure compliance. Our chart auditors will review the EHR periodically for this form to ensure completion.
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709.81(b)(2)(i) LICENSURE Intake and admission
709.81. 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:
(i) Project policies.
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Observations
The facility failed to provide intake documentation verifying that the client was oriented to the program in two of four client records reviewed.
Client #8 was admitted on June 26, 2018 and was discharged on July 10, 2018.
Client #9 was admitted on January 23, 2018 and was discharged on March 23, 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will educate all staff about beginning to use a form that was utilized in the past that clearly documents that the client was oriented to the program. This has been completed effective 11/29/18.
When the program moved this past year, somehow we missed utilizing this form.
Further, the Clinical Supervisor will ensure that the form will be added into our new EHR to help ensure compliance. Our chart auditors will review the EHR periodically for this form to ensure completion. |
709.83(a) LICENSURE Client records
709.83. 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:
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Observations
The facility failed to document and provide a complete client record in one of four client records reviewed.
Client #8 was admitted on June 26, 2018 and was discharged on July 10, 2018. The client record was missing records of services for the entire treatment episode. There was progress note documentation that the client was seen during that time period. Additionally, the client record did not have documentation of post-discharge follow-up information as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
We began using our new EHR and there is an electronic record of all services for every client. The Clinical Supervisor will conduct random chart audit checks to ensure the required record of services are documented. Further, the clinical supervisor will educate all staff on the use of the EHR and how to document the records of service. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
The facility failed to include documentation of a preliminary treatment plan during the intake and admission period in two of five client records reviewed.
Client #4 was admitted on November 2, 2017 and was discharged on April 15, 2018.
Client #5 was admitted on January 19, 2018 and was discharged on August 6, 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1) A treatment plan will be completed for all clients on day of intake and updated according to the level of care the client is receiving services--either 30 days for Partial hospitalization or 60 days for out patient. The TP will be signed by the therapist, the client, and the doctor.
2) Therapists will be educated on the DDAP regulations through staff meetings and supervisory meetings.
3)Supervisory staff will run reports within the EHR to ensure accurate and timely TP documentation. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. 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:
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Observations
The facility failed to properly document that the individual's comprehensive treatment and rehabilitation plan was developed with the client in two of five client records reviewed.
Client #3 was admitted on December 11, 2017 and was discharged on June 25, 2018. The client's record did not contain an outpatient comprehensive treatment plan for the entire duration of client's treatment episode.
Client #5 was admitted on January 19, 2018 and was discharged on August 6, 2018. The comprehensive treatment plan was signed and dated February 6, 2018 by facility staff; however, there was no client signature or written documentation that the plan was developed with the client's input.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1)The Clinical Supervisor will educate therapists about the importance of clients being involved in developing the TP. This will be reviewed in staff meetings and individual supervisory sessions.
2) The Clinical Supervisor will run reports on a regular basis to ensure client signatures are on TP's. |
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
The facility failed to provide treatment plan updates within the regulatory timeframe in three of five client records reviewed.
Client #1 was admitted on August 11, 2017 and was still active at the time of inspection. A treatment plan update was completed on January 20, 2018 and the next update was due no later than March 20, 2018; however, the update was not completed until July 9, 2018. Additionally, the next treatment plan update was due no later than September 9, 2018, but the update was no completed until October 9, 2018.
Client #2 was admitted on March 7, 2018 and was still active at the time of the inspection. The comprehensive treatment plan was completed on April 5, 2018 and the first update was due no later than June 5, 2018; however, the update was not completed until July 5, 2018. Additionally, the next treatment plan update was due no later than September 5, 2018, but was not completed until October 9, 2018.
Client #5 was admitted on January 19, 2018 and was discharged on August 6, 2018. The comprehensive treatment plan was completed on February 6, 2018 and the first update was due no later than April 6, 2018; however, the update was not completed prior to client's discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will educate all staff about the DDAP requirement of TP updates being required every 60 days. This has been done effective 11/29/18. With our new EHR, therapists and supervisors will be notified, electronically, 14 days of their TP update being due. Additionally, the Clinical Supervisor will run reports regularly to ensure compliance. |
709.93(a) 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:
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Observations
The facility failed to document and provide a complete client record in five of five client records reviewed.
Client #1 was admitted on August 11, 2017 and was still active at the time of the inspection. The client record was missing records of services from May 2018 through November 2018. There was progress note documentation that the client was seen during that time period.
Client #2 was admitted on March 7, 2018 and was still active at the time of the inspection. The client record was missing records of services from April 2018 through November 2018. There was progress note documentation that the client was seen during that time period.
Client #3 was admitted on December 11, 2017 and was discharged on June 25, 2018. The client record did not have documentation of post-discharge follow-up information as of the date of the inspection.
Client #4 was admitted on November 2, 2017 and was discharged on April 15, 2018. The client record did not have documentation of post-discharge follow-up information as of the date of the inspection.
Client #5 was admitted on January 19, 2018 and was discharged on August 6, 2018. The client record was missing records of services from April 2018 through August 2018. There was progress note documentation that the client was seen during that time period. Additionally, the client record did not have documentation of post-discharge follow-up information as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
NVWR began using our new EHR. With this system it will automatically keep a record of service for every client. This has been completed. The office assistant will conduct chart reviews to ensure that there is a record of service for all clients.
A discharge information sheet has been added to our discharge summary in our new EHR. This information sheet will list the date and time of the client's next appointment after being discharged from NVWR. This has been completed. The office assistant will conduct chart reviews to ensure that the records of service and discharge information and follow-up is completed.
A discharge follow-up case management note will be entered in the EHR by therapists within 14 days of discharge to ensure follow-up care. The Clinical Supervisor educated all staff about this responsibility on 11/29/18. This has been completed. The office assistant will conduct chart reviews to ensure the follow-up and follow-up note is completed.
Client # 1-- is an active client at the time of this CAP. His therapist will complete the record of service on him by 12/14/18.
Client #2--is an active client at the time of this CAP. Her therapist will complete the record of service on her by 12/14/18.
Client #3--was discharged June 25, 2018. The office assistant will make a follow-up call to her and document it in her chart by 12/10/18.
Client #4- was discharged April 15, 2018. The office assistant will make a follow-up call to him and document it in her chart by 12/10/18.
Client #5- was discharged August 6, 2018. The office assistant will make a follow-up call to her and document it in her chart by 12/10/18. |