INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 2, 2023by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Sarah Jane Bentley Foundation 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, the facility failed to document that each counselor met both the education and experiential qualifications for the position.Employee #2 who was hired as a counselor on February 1, 2023, did not meet the education requirements to be a counselor. At the time of the hire, the employee had an MBA which is not a qualifying degree to be a counselor. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
After receiving audit results it was determined Employee #2 who was hired as a counselor on February 1, 2023, did not meet the education requirements to be a counselor. At the time of the hire, the employee had an MBA which is not a qualifying degree to be a counselor. After the completion of the audit, the Program Director was able to meet with clinical staff to discuss findings pertaining to the audit. The Program Director informed Employee #2 who was hired as a counselor on February 1, 2023, that it was determined that she did not meet the education requirements to be a counselor, therefore she was offered CA position. A staff member declined the CA position and informed the program Director her last day would be Oct. 31, 2023. The Program Director was able to review previous resumes and was able to hire a clinical supervisor on who plan to start on October 30, 2023. |
704.11(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
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Observations
Based on a review of the facility's staff development program, the facility failed to develop an assessment of staffing training needs for the current training year, January 1, 2023 through December 31, 2023. This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will meet with clinical staff individually no later than November 13, 2023, to identify staff training needs and create training plans identifying training needs which counselors will complete within time. |
704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of the facility's staff development program, the facility failed to develop an overall plan for addressing training needs for the current training year, January 1, 2023 through December 31, 2023. This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will meet with clinical staff individually to identify staffing training needs and create training plans in order to develop training needs by November 30 2023.
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704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of the facility's staff development program and a discussion with facility staff, the facility failed to develop a mechanism to collect feedback on completed trainings. This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The program director will develop an evaluation training form where staff will be able to discuss feedback on training outcomes in order to best provide services that are beneficial for staffing growth by November 30 2023. |
704.11(a)(4) LICENSURE Evaluation of Overall Plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a review of the facility's staff development program, the facility failed to develop an annual evaluation of the overall training plan for the current training year, January 1, 2023 through December 31, 2023. This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
CS and the program director will meet with staff individually in order to develop overall training plans, annually, and monthly as needed in order to assist staff with developing skills and addressing their staffing needs during monthly supervision. November 30, 2023 |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the January 2023 through September 2023 fire drill logs, the facility failed to document the exit routes used and whether the fire alarm or smoke detector was operative.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The program director will develop a fire drill log, which will consist of the facility's exit used and whether the fire alarm or smoke detector was operative, the Expected time of Evacuation #of Clients \Presented as well as a summary of the drill no later than November 30, 2023.
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705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the January 2023 through September 2023 fire drill logs, the facility failed to document whether a fire alarm or smoke detector was set off during the time of the drill. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The program director will develop a fire drill log, which will consist of when the facility's exit was used and whether the fire alarm or smoke detector was operative, during the time of the drill by November 30, 2023 |
709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
Based on a discussion with facility staff, the facility failed make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will correct deficiencies by implementing the following steps to gain compliance. The Program Director will be responsible for updating the website to include names of officers, directors, principal shareholders, and annual reports no later than Dec. 31, 2023, and as needed thereafter checking in monthly with board members for any updates that need to be implemented. The Program Director submitted an exception request due to financial Audits and the program not exceeding $500.000 |
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 a review of the facility's policy and procedure manual, the facility failed to document a written procedure and time frame for the completion of client follow up information. This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Project Director will update and implement a written procedure and time of completion for follow-up after the client has been discharged. The clinical supervisor will review with the clinical staff the follow-up policy no later than Nov. 30, 2023. The counselor will be responsible for completing follow-up calls within 7days of discharge. The counselor will also be responsible for sending a letter of discharge with resources. The clinical Supervisor or Program director will audit charts weekly to ensure discharge summaries, letters, and follow-up calls have been completed within the time frame. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a review of administrative documents and an interview with the facility director, the project failed to document an annual financial audit for the fiscal year ending December 31, 2022. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director has submitted an Exception Request due to gross revenue received not exceeding $500,000. The Program Director will take responsibility for ensuring the website is updated annually or as needed in order to make the public aware of the financial status, which will be compopleted no later than Nov.30,2023 |
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 consent to release information form prior to releasing information in seven out of seven records reviewed. There was no consent to release information forms for the funding source. Facility staff confirmed billing had occurred.Client #1 was admitted on July 10, 2023 and was still active at the time of the inspection.Client #2 was admitted on July 7, 2023 and was still active at the time of the inspection.Client #3 was admitted on May 23, 2023 and was still active at the time of the inspection. Client #4 was admitted on July 25, 2023 and was still active at the time of the inspection. Client #5 was admitted on March 6, 2023 and was discharged on March 31,2023. Client #6 was admitted on February 16, 2023 and was discharged March 14, 2023. Client #7 was admitted on February 7, 2023 and was discharged on April 17, 2023. These findings were reviewed with facility staff during the licensing inspection
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Plan of Correction
Counselor will review client charts to ensure all consents have signed day of admission. Counselors will began reviewing current charts within 60 days no later than December 31,2023 in order to bring charts up to compliance. CS will audit charts to ensure client charts have been updated daily moving forward. CS will complete group supervision to ensure all counselors are trained and understand the importance of completing consents during admission and as needed. CS will review admission process which consist of but not limited to the following, consents and admission paperwork. |
709.30 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.
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Observations
Based on a review of seven client records and a discussion with facility staff, the facility failed to document written acknowledgement by clients that they have been notified of their client rights in all seven client records reviewed.Client #1 was admitted on July 10, 2023 and was still active at the time of the inspection.Client #2 was admitted on July 7, 2023 and was still active at the time of the inspection.Client #3 was admitted on May 23, 2023 and was still active at the time of the inspection. Client #4 was admitted on July 25, 2023 and was still active at the time of the inspection. Client #5 was admitted on March 6, 2023 and was discharged on March 31,2023. Client #6 was admitted on February 16, 2023 and was discharged March 14, 2023. Client #7 was admitted on February 7, 2023 and was discharged on April 17, 2023. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counselors will began updating client charts to ensure all clients have reviewed and signed client rights. Counselors will began reviewing current charts in order to gain compliance within 60 days no later than December 31, 2023. CS will audit charts to ensure clients have signed the client rights policy and charts have been updated. CS will complete group supervision to ensure all counselors are trained and understand the importance of client rights. The supervisor will continue to audit charts during admission. Counselors will ensure client bills of rights are reviewed and signed annually. CS will review charts daily to ensure charts remain in compliance. The clinical Supervisor will review and introduce peer audits to clinical staff beginning January 1, 2024 to ensure all charts reamin in compliance. |
709.31 (b) LICENSURE Data collection system
§ 709.31. Data collection system.
(b) The recordkeeping system must allow for the identification of clients' admissions and discharges within a specific time period.
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Observations
Based on a review of client records and discussion with facility staff, the facility's record keeping system did not allow for the identification of client's admission and discharges within a specific time period. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The program Director and Clinical supervisor will review client charts to ensure admission dates as well as discharge dates are included. The program director will reach out to the current EMR system to ensure admission dates, as well as discharge dates, are included on all documentation within 60 days. The clinical supervisor will review and train staff on navigating through the system to ensure all client records are dated. Counselors will be responsible for ensuring all records are dated upon admission and discharge. The clinical supervisor will continue to audit admission/ discharge charts daily this plan will begin as of Nov 15,2023. |
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.
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Observations
Based on a review of client records, the facility failed to document that client was oriented to the project policies in seven out of seven records reviewed.Client #1 was admitted on July 10, 2023 and was still active at the time of the inspection.Client #2 was admitted on July 7, 2023 and was still active at the time of the inspection.Client #3 was admitted on May 23, 2023 and was still active at the time of the inspection. Client #4 was admitted on July 25, 2023 and was still active at the time of the inspection. Client #5 was admitted on March 6, 2023 and was discharged on March 31,2023. Client #6 was admitted on February 16, 2023 and was discharged March 14, 2023. Client #7 was admitted on February 7, 2023 and was discharged on April 17, 2023. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinicians will be responsible for correcting current deficiencies and will ensure all future clients have received the client handbook as of Nov. 15, 2023 The clinical supervisor/Program director will review client charts to ensure all present and future clients have been orientated to the program. Each client will verify that they have attended the orientation group and have received the client handbook by signing documentation Counselors will be responsible for uploading these documents in client charts. The clinical supervisor will review current charts in addition to admission charts daily/weekly to ensure documents have been signed. This will ensure these deficiencies do not occur again. After clients have signed these documents will be uploaded to client charts |
709.91(b)(2)(ii) 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:
(ii) Hours of operation.
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Observations
Based on a review of client records, the facility failed to document that the client was oriented to the project's hours of operation in seven out of seven records reviewed.Client #1 was admitted on July 10, 2023 and was still active at the time of the inspection.Client #2 was admitted on July 7, 2023 and was still active at the time of the inspection.Client #3 was admitted on May 23, 2023 and was still active at the time of the inspection. Client #4 was admitted on July 25, 2023 and was still active at the time of the inspection. Client #5 was admitted on March 6, 2023 and was discharged on March 31,2023. Client #6 was admitted on February 16, 2023 and was discharged March 14, 2023. Client #7 was admitted on February 7, 2023 and was discharged on April 17, 2023. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinicians will be responsible for correcting deficiencies in current client charts and will ensure all future clients have received client handbook which includes the project's hours of operation . Clinical supervisor/Program director will review client charts to ensure all present and future clients have been made aware of program hours by attending orentation group witin 14 days of addmission. Each client will verify that they have attended orientation group and have received client handbook. Counselors will be responsible for uploading these documents in client charts. Clinical supervisor will review charts daily/weekly to ensure documents have been signed. This will ensure these deficiencies dose not occur again. these documents will be uploaded to client charts. The plan is to have these charts up dated by Dec. 31,2023.
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709.91(b)(2)(iii) 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:
(iii) Fee schedule.
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Observations
Based on a review of client records, the facility failed to document that the client was oriented to the facility's fee schedule in seven out of seven records reviewed.Client #1 was admitted on July 10, 2023 and was still active at the time of the inspection.Client #2 was admitted on July 7, 2023 and was still active at the time of the inspection.Client #3 was admitted on May 23, 2023 and was still active at the time of the inspection. Client #4 was admitted on July 25, 2023 and was still active at the time of the inspection. Client #5 was admitted on March 6, 2023 and was discharged on March 31,2023. Client #6 was admitted on February 16, 2023 and was discharged March 14, 2023. Client #7 was admitted on February 7, 2023 and was discharged on April 17, 2023. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinicians will be responsible for correcting deficiencies in current client charts and will ensure all future clients have received client handbook which includes the program fees for services. Clinical supervisor/Program director will review client charts to ensure all present and future clients have been made aware of program fees by attending orientation group within 14 days of admission. Each client will verify that they have attended orientation group and have received client handbook which will include program fees. Counselors will be responsible for uploading these documents in client charts. Clinical supervisor will review charts daily/weekly to ensure documents have been signed. This will ensure these deficiencies does not occur again. Documents will be uploaded to current client charts. The plan is to have these charts updated by Dec. 31,2023. |
709.91(b)(2)(iv) 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:
(iv) Services provided.
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Observations
Based on a review of client records, the facility failed to document that the client was oriented to the services provided in seven out of seven records reviewed.Client #1 was admitted on July 10, 2023 and was still active at the time of the inspection.Client #2 was admitted on July 7, 2023 and was still active at the time of the inspection.Client #3 was admitted on May 23, 2023 and was still active at the time of the inspection. Client #4 was admitted on July 25, 2023 and was still active at the time of the inspection. Client #5 was admitted on March 6, 2023 and was discharged on March 31,2023. Client #6 was admitted on February 16, 2023 and was discharged March 14, 2023. Client #7 was admitted on February 7, 2023 and was discharged on April 17, 2023. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinicians will be responsible for correcting deficiencies in current client charts within 60 days Dec. 31,2023. CS will review client handbook with staff members and confirm all counselors have access to handbook which will included types of services offered to clients as well as treatment expectations while enrolled at Sarah Jane Bentley Foundation. Clinical Supervisor/Program director will review client charts to ensure all present and future clients have been orientated to the program by attending orientation group within 14 days of admission and sign off on being aware of services offered upon admission, this will be verified by client signatures. |
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.
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Observations
Based on a review of seven client records, the facility failed to document a complete medical history in three of seven client records. Client #1 was admitted on July 10, 2023 and was still active at the time of the inspection.Client #3 was admitted on May 23, 2023 and was still active at the time of the inspection. Client #5 was admitted on March 6, 2023 and was discharged on March 31,2023These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CS will complete a training within 30 days with clinical staff reviewing the process for completing intakes which will include, screening tool, Bio assessments which would included medical, social and physical history. Clinicians will be responsible for correcting deficiencies in current client charts within 60 days. CS will review clients to ensure these charts have been corrected. Clinical supervisor will review charts daily/weekly to ensure documents have been completed day of admission. This will ensure these deficiencies does not occur again. The plan is to have these charts updated by Dec. 31,2023. |
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.
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Observations
Based on a review of seven client records, the facility failed to document a complete drug and alcohol history in four of seven client records. Client #1 was admitted on July 10, 2023 and was still active at the time of the inspection.Client #5 was admitted on March 6, 2023 and was discharged on March 31, 2023.Client #6 was admitted on February 16, 2023 and was discharged March 14, 2023. Client #7 was admitted on February 7, 2023 and was discharged on April 17, 2023. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CS will review process for completing these deficiencies within 30 days with clinical staff. CS will train clinical staff on the process for completing admission process which shall include completing admission paper work the importance of gathering data and completing Bio psychosocial within 5 days of admission. Clinicians will be responsible for correcting deficiencies in current client charts within 60 days. CS will review client charts to ensure these charts have been corrected. Clinical supervisor will review charts daily/weekly moving forward to ensure documents have been completed within 5 days of admission. This will ensure these deficiencies does not occur again. The plan is to have these charts updated by Dec. 31,2023. |
709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on the review of client records and discussion with facility staff, the facility failed to document a consent to treatment in all seven client records reviewed. Client #1 was admitted on July 10, 2023 and was still active at the time of the inspection.Client #2 was admitted on July 7, 2023 and was still active at the time of the inspection.Client #3 was admitted on May 23, 2023 and was still active at the time of the inspection. Client #4 was admitted on July 25, 2023 and was still active at the time of the inspection. Client #5 was admitted on March 6, 2023 and was discharged on March 31,2023. Client #6 was admitted on February 16, 2023 and was discharged March 14, 2023. Client #7 was admitted on February 7, 2023 and was discharged on April 17, 2023. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
CS will review process for completing these deficiencies within 30 days with clinical staff. CS will train clinical staff on the process for completing the admission process which shall include completing admission paper work , reviewing the importance of signing consents for treatment day of admission. Clinicians will be responsible for correcting deficiencies in current client charts within 30 days. CS will review client charts to ensure these charts have been corrected. Counselors will began meeting with clients to ensure all consents are signed and uploaded to client charts. Clinical supervisor will review charts daily/weekly moving forward to ensure documents have been completed day of admission. This will ensure these deficiencies does not occur again. The plan is to have these charts updated by Dec. 31,2023.
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709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to document a complete psychosocial evaluation in all seven client records reviewed. . Client #1 was admitted on July 10, 2023 and was still active at the time of the inspection.Client #2 was admitted on July 7, 2023 and was still active at the time of the inspection.Client #3 was admitted on May 23, 2023 and was still active at the time of the inspection. Client #4 was admitted on July 25, 2023 and was still active at the time of the inspection. Client #5 was admitted on March 6, 2023 and was discharged on March 31,2023. Client #6 was admitted on February 16, 2023 and was discharged March 14, 2023. Client #7 was admitted on February 7, 2023 and was discharged on April 17, 2023. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
CS will review process for completing these deficiencies within 30 days with clinical staff. CS will train clinical staff on the process for completing psychosocial Clinicians will be responsible for correcting deficiencies in current client charts within 60 days. CS will review client charts to ensure these charts have been corrected. Counselors will began meeting with clients to ensure psychosocial have been completed and signed. Clinical supervisor will review charts daily/weekly moving forward to ensure documents have been completed within a timely manner. This will ensure these deficiencies does not occur again. The plan is to have these charts updated by Dec. 31,2023. |
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
Based on a review of six applicable client records, the facility failed to ensure that an individual treatment and rehabilitation plan shall be developed with the client as treatment plans are not signed by the client and/or documented that the client had input all six applicable client records. Client #1 was admitted on July 10, 2023 and was still active at the time of the inspection.Client #2 was admitted on July 7, 2023 and was still active at the time of the inspection.Client #3 was admitted on May 23, 2023 and was still active at the time of the inspection. Client #4 was admitted on July 25, 2023 and was still active at the time of the inspection. Client #6 was admitted on February 16, 2023 and was discharged March 14, 2023. Client #7 was admitted on February 7, 2023 and was discharged on April 17, 2023. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CS will review process for completing these deficiencies within 30 days with clinical staff. CS will train clinical staff on the process for completing comprehensive treatment plans, updated and signed every 60 days or as needed. Clinicians will be responsible for correcting deficiencies in current client charts within 60 days. CS will review client charts to ensure these charts have been corrected. Counselors will began meeting with clients to ensure treatment plans have been signed. Counselors will begin printing treatment plans to ensure client has reviewed their treatment goals and updated them in client charts. This will ensure these deficiencies does not occur again. The plan is to have these charts updated by Dec. 31,2023 |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document type and frequency of the treatment and rehabiliation services in all six applicable client records reviewed. Client #1 was admitted on July 10, 2023 and was still active at the time of the inspection.Client #2 was admitted on July 7, 2023 and was still active at the time of the inspection.Client #3 was admitted on May 23, 2023 and was still active at the time of the inspection. Client #4 was admitted on July 25, 2023 and was still active at the time of the inspection. Client #6 was admitted on February 16, 2023 and was discharged March 14, 2023. Client #7 was admitted on February 7, 2023 and was discharged on April 17, 2023. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CS will review process for completing these deficiencies within 30 days with clinical staff. CS will train clinical staff on the process for completing treatment plans which should include SMART . CS will review process for treatment plans which should include duration, frequency of treatment goals. Clinicians will be responsible for correcting deficiencies in current client charts within 60 days. CS will review client charts to ensure these charts have been corrected. Counselors will began meeting with clients to ensure treatment plans have been signed due to changes .This will ensure these deficiencies does not occur again. The plan is to have these charts updated by Dec. 31,2023 |
709.93(a)(4) 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:
(4) Referral contact.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to a referral contact in seven out of seven client records.Client #1 was admitted on July 10, 2023 and was still active at the time of the inspection.Client #2 was admitted on July 7, 2023 and was still active at the time of the inspection.Client #3 was admitted on May 23, 2023 and was still active at the time of the inspection. Client #4 was admitted on July 25, 2023 and was still active at the time of the inspection. Client #5 was admitted on March 6, 2023 and was discharged on March 31,2023. Client #6 was admitted on February 16, 2023 and was discharged March 14, 2023. Client #7 was admitted on February 7, 2023 and was discharged on April 17, 2023. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The counselor will be responsible for documenting all referrals given to the client during the session or as needed. For clients who are being discharged from the program, referral sources will be included in the discharge summary beginning Nov. 15, 2023. |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on a review of client records, the facility failed to provide a complete client record which is to include progress notes with relative information to the client's involvement with the facility in seven out of seven client records reviewed. Client #1 was admitted on July 10, 2023 and was still active at the time of the inspection.Client #2 was admitted on July 7, 2023 and was still active at the time of the inspection.Client #3 was admitted on May 23, 2023 and was still active at the time of the inspection. Client #4 was admitted on July 25, 2023 and was still active at the time of the inspection. Client #5 was admitted on March 6, 2023 and was discharged on March 31,2023. Client #6 was admitted on February 16, 2023 and was discharged March 14, 2023. Client #7 was admitted on February 7, 2023 and was discharged on April 17, 2023. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The clinical Supervisor will complete group supervision on the importance of completing progress notes day of services. CS will complete training on best practices pertaining to progress notes. Counselors will be responsible for completing these notes daily. CS will spot-check to ensure all DAP /progress notes are being completed daily as of Nov. 15,2023 |
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 a review of client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in four out of six applicable records reviewed. The facility's policy and procedures manual states that a case consultation is to be completed every 60 days. Client #3 was admitted on May 23, 2023 and was still active at the time of the inspection. A case consultation was due to be completed no later than July 23, 202; however, no case consultation was documented in the client record at the time of the inspection.Client #4 was admitted on July 25, 2023 and was still active at the time of the inspection. A case consultation was due to be completed no later than September 25, 2023; however, no case consultation was documented in the client record at the time of the inspection.Client #7 was admitted on February 7, 2023 and was discharged on April 17, 2023. A case consultation was due to be completed no later than April 7, 2023; however, no case consultation was documented in the client record at the time of the inspection.These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The clinical supervisor will review with clinical staff policy pertaining to completing case consultations. Counselors will be responsible for completing these documents every 60 days. CS will audit client charts monthly and counselors will complete chart audits monthly to ensure these deficiencies do not recur in the future as of Nov 30,2023 |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include aftercare information in two out of two applicable discharged records reviewed.Client #6 was admitted on February 16, 2023 and was discharged March 14, 2023. Client #7 was admitted on February 7, 2023 and was discharged on April 17, 2023. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical supervisor will review with clinical staff process for completing aftercare documentation. All clients will be required to complete an aftercare plan 30 days prior to discharge date. Counselor will be responsible for completing aftercare plan with al clients, this document will require both parties signatures. Client will be given a copy .This training will occur by November 30,2023. CS will review chart 30days prior to discharge date to ensure aftercare has been completed prior to discharge. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include a discharge summary in two out of three applicable discharged records reviewed.Client #6 was admitted on February 16, 2023 and was discharged March 14, 2023. Client #7 was admitted on February 7, 2023 and was discharged on April 17, 2023. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
CS and counselors will begin reviewing discharge charts to complete discharge summaries as of Nov.15,2023. Moving forward the steps to ensure this deficiency does not reoccur are the following, counselors will be responsible for notifying CS via email to review the client chart before completing discharge. CS will review charts for corrections. After the discharge chart has been approved counselor will then forward a letter of discharge to the client which will include recovery resources and the reason for discharge. All discharge summaries will be completed within 7 days after discharge date. |
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 provide a complete client record, which is to include follow up information in three of three applicable discharged records reviewed.Client #5 was admitted on March 6, 2023 and was discharged on March 31,2023. Client #6 was admitted on February 16, 2023 and was discharged March 14, 2023. Client #7 was admitted on February 7, 2023 and was discharged on April 17, 2023. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical supervisor will review with clinical staff follow up/discharge policy pertaining to completing discharge summaries within 7 days of discharge date. Counselor will be responsible for completing discharge summary that captures client course of treatment and documented. Counselor will complete follow up calls within 7days of discharge. Counselor will also be responsible for sending letter of discharge with resources to all clients. Clinical Supervisor or Program director will audit charts weekly to ensure discharge summary, letters and follow up calls has been completed within time frame as of Nov 30,2023 |