INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on February 23, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, Persad Center 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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709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
Based on the physical plant inspection, the facility failed to keep hard copy client records in a secured locked room that is not accessible to undesignated staff. Overflow client records were being stored in a room that could be accessed by all staff.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The files mentioned in observation #0275 will be boxed up and moved to another area in our building that is not being utilized at this time due to COVID-19. These files will be behind 2 locked doors and will have restricted access. This task will be completed no later than April 15, 2021. |
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 seven 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 # 2 was admitted on January 16, 2020 and was still active at the time of the inspection. An informed and voluntary consent from the client signed and dated on February 11, 2020 to a probation officer did not provide the specific information to be disclosed. Also, to a public defender's office, the informed and voluntary consent from the client dated February 11, 2020 allowed for the release of psychological testing, discharge summary, medication, treatment progress, treatment summary, treatment plan, intake information, service dates and type, HIV status, physical exam, aftercare plan, and psychosocial.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from September 19, 2019 inspection.
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Plan of Correction
Client #2 is in process of being re-assigned. Once the case is re-assigned (which will be by 3/15/21) I will have the therapist complete a new consent to release form with the correct information indicated to be released. I will also be having a review of confidentiality regulations with all the therapists on 4/5/21 to ensure that everyone is aware of the regulations and how to appropriately complete these forms. Our new EHR system will also allow me to review consents in real-time to reduce potential of these kinds of errors. |
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 one of seven 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 # 2 was admitted on January 16, 2020 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information contained in the client record signed and dated on February 11, 2020 to a probation officer and to a public defender's office 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
Client #2 is in process of being re-assigned. Once the case is re-assigned (which will be by 3/15/21) I will have the therapist complete a new consent to release form with the correct information indicated to be released. I will also be having a review of confidentiality regulations with all the therapists on 4/5/21 to ensure that everyone is aware of the regulations and how to appropriately complete these forms. Our new EHR system will also allow me to review consents in real-time to reduce potential of these kinds of errors. |
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
Based on five of seven client records reviewed, the facility failed to provide documentation of treatment and rehabilitation plans being reviewed and updated at least every sixty days in client records # 2, 3, 5, 6, and 7.
Client # 2 was admitted on January 16, 2020 and was still active at the time of the inspection. The comprehensive treatment plan was developed with the client on January 16, 2020. A treatment plan update was due no later than March 16, 2020. The next treatment plan update did not occur until August 21, 2020. Also, a treatment plan update occurred on October 2, 2020 and a treatment plan update was to occur no later than December 2, 2020. There was not another treatment plan update in the client record.
Client # 3 was admitted on February 3, 2020 and was still active at the time of the inspection. The comprehensive treatment plan was developed with the client on February 4, 2020. A treatment plan update was due to occur no later than April 4, 2020 but did not occur until June 19, 2020. The next update was due no later than August 19, 2020 but did not occur until September 2, 2020.
Client # 5 was admitted on February 19, 2020 and was discharged on October 26, 2020. The comprehensive treatment plan was developed with the client on February 19, 2020. A treatment plan update was due to occur no later than April 19, 2020 but did not occur until May 22 , 2020. The next update was due no later than July 22, 2020 but did not occur until August 10, 2020.
Client # 6 was admitted on March 15, 2018 and was discharged on September 19, 2020. A treatment plan update occurred on April 30, 2020 and the next update was due no later than June 30, 2020 but did not occur until July 1, 2020. The next update was due no later than September 1, 2020 but there were no other updates in the client record.
Client # 7 was admitted on March 4, 2020 and was discharged on June 12, 2020. The Comprehensive treatment plan was developed with the client on March 10, 2020. A treatment plan update was due to occur no later than May 10, 2020. There were no other updates in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 2/1/21 we have moved over to an EHR, this system will provide prompts/alerts for when treatment plan reviews are coming due to ensure that they are completed in a timely manner. I will also be reviewing treatment planning regulations with all of my therapists on 4/5/21 to ensure that everyone is aware of the timeframes related to these plans and reviews. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on six of seven client records reviewed, the facility failed to provide documentation of counseling services being provided according to the individual treatment and rehabilitation plan in client records # 1, 2, 3, 4, 5, and 7.
Client # 1 was admitted on November 5, 2020 and was still active at the time of the inspection. A comprehensive treatment plan developed with the client on November 5, 2020 indicated Individual therapy sessions to occur weekly. A treatment plan update on January 8, 2021 indicated individual therapy sessions to occur weekly. The client record indicated there were no individual session the following weeks:
November 8-14, 22-28, 29- December 5, 6-12, 13-19, 27- January 2, 17-23, 31- February 6, 7-13, 14-20.
Client # 2 was admitted on January 16, 2020 and was still active at the time of the inspection. A comprehensive treatment plan developed with the client on January 16, 2020 indicated individual therapy sessions and group sessions to occur bi-weekly. A treatment plan update on August 21 and October 2, 2020 indicated individual therapy sessions and group sessions to occur weekly. The client record indicated there were no group sessions the months/weeks of December, January, and February 1- 19.
Individual sessions did not occur the weeks/months of:
September 19-November 19, December 1-31, January 10-16, 17-23, 31-February 6, 7-13, 14-20.
Client # 3 was admitted on February 3, 2020 and was still active at the time of the inspection. A treatment plan update occurred on January 8, 2021 that indicated individual therapy sessions occur bi-weekly. The last documented individual therapy session occurred on January 29, 2021.
Client # 4 was admitted on August 24, 2020 and was still active at the time of the inspection. A comprehensive treatment plan developed with the client on October 2, 2020 indicated Individual therapy sessions weekly. Treatment plan updates occurred on December 11, 2020 and February 9, 2021 that indicated individual therapy sessions occur weekly. The client record indicated there were no individual session the following weeks:
October 4-17, December 6-12, 20-January 2, 17-23, 31- February 20.
Client # 5 was admitted on February 19, 2020 and was discharged October 26, 2020. A comprehensive treatment plan developed with the client on February 19, 2020 indicated Individual therapy sessions and group sessions to occur weekly. There were no group sessions documented August 10-September 14 and no individual sessions documented August 30-September 15. A treatment plan update occurred on September 29, 2020 that indicated individual therapy sessions occur weekly. The client record indicated there were no individual session the following weeks:
September 13-19.
Client # 7 was admitted on March 4, 2020 and was discharged June 12, 2020. A comprehensive treatment plan developed with the client on March 10, 2020 indicated Individual therapy sessions and group sessions to occur weekly. The last documented group session occurred on March 19, 2020 and the last documented individual session occurred on March 9, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 2/1/21 Persad Center, Inc. has moved to an EHR, this will allow the Clinical Supervisor & Clinical Director to review records with more efficiency and be able to identify these kinds of errors in real-time. The Clinical Supervisor will be reviewing the need for appropriate documentation with all of my therapists on 4/5/21. The Clinical Supervisor will be reviewing charts on a weekly basis to ensure that this corrective action has been implemented. |
709.93(a)(3) 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:
(3) Record of services provided.
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Observations
Based on seven of seven client records reviewed, the facility failed to provide a complete client record on an individual which includes information relative to the client's involvement with the project to include a complete record of service. The record of service provided in the client's records did not include all services provided to the client.
Client # 1 was admitted on November 5, 2020 and was still active at the time of the service. The client record of service did not include documentation of individual or group sessions the client attended.
Client # 2 was admitted on January 16, 2020 and was still active at the time of the service. The client record of service did not include documentation of individual or group sessions the client attended.
Client # 3 was admitted on February 3, 2020 and was still active at the time of the service. The client record of service did not include documentation of individual or group sessions the client attended.
Client # 4 was admitted on August 24, 2020 and was still active at the time of the service. The client record of service did not include documentation of individual or group sessions the client attended.
Client # 5 was admitted on February 19, 2020 and was discharged October 26, 2020. The client record of service did not include documentation of individual or group sessions the client attended.
Client # 6 was admitted on March 15, 2018 and was discharged September 19, 2020. The client record of service did not include documentation of individual or group sessions the client attended.
Client # 7 was admitted on March 4, 2020 and was discharged June 12, 2020. The client record of service did not include documentation of individual or group sessions the client attended.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Persad Center, Inc. began transitioning over to electronic health record on 2/1/21. This transition will allow for a more comprehensive client record which will include the items for which we were deficient on. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on three of six applicable client records reviewed, the facility failed to provide a complete client record to include case consultation notes in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate case consultations to occur at least quarterly for the first year of service.
Client # 2 was admitted on January 16, 2020 and was still active at the time of the inspection. A case consultation was due no later than April 24, 2020. There was not a case consultation documented in the client record.
Client # 3 was admitted on February 3, 2020 and was still active at the time of the inspection. A case consultation was due no later than May 3, 2020. There was not a case consultation documented in the client record.
Client # 5 was admitted on February 19, 2020 and was discharged on October 26, 2020. A case consultation was due no later than May 19, 2020. There was not a case consultation documented in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
EHR will allow me the ability to review records in real-time and see who has consults coming up/overdue. The Clinical Supervisor will be reviewing the frequency with which these need to be done with all of the therapists on 4/5/21. Moving forward case consults will be completed around the same time as plan reviews (for clients in first year of treatment). They will occur every 6 months after that for the duration of treatment. The Clinical Supervisor will be reviewing charts on a weekly basis to ensure that this documentation is completed. |