INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 28, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, RHD Family House 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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705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to instruct and document that all staff in the use of the fire extinguisher upon employment in one of four personnel records reviewed.
Employee #3 was hired as a clinical supervisor on May 22, 2023. The documentation in the record indicated that the fire extinguisher training was provided on July 14, 2023.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, Program Director / Life Skill Supervisor will complete the on-boarding of new hires that includes emergency training with all new employees within the first 7 days of hire. Program Director will review new staff files monthly to ensure fire extinguisher training is completed in a timely manner. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility's July 2022 through July 2023 fire drill logs, the facility failed to conduct unannounced fire drills at least once a month as there was no documentation that a drill was completed during the month of June 2023.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will conduct a monthly review of the fire drill log book to ensure accurate completion of the monthly report. Program Director will also collaborate with Life skills Supervisor to ensure all fire drills are appropriately documented. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on review of personnel records, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies in one of four personnel records reviewed.
Employee #3 was hired as a clinical supervisor on May 22, 202. The documentation in the records indicated that the emergency preparedness training was not provided until July 14, 2023.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, Residential Manager will complete onboarding that includes emergency training with all new employees within the first 7 days of hire. Program Director will review new staff files monthly to ensure emergency preparedness training is completed in a timely manner. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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 review of the facility's July 2022 through July 2023 fire drill logs, the facility failed to identify the number of persons in facility at the time of the drill on every fire drill log completed during the reviewed period
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director and Residential Manager will provide by August 31, 2023 to all staff on how to complete the updated fire drill record report which includes date, time, amount of time it took for evacuation, exit route used, number of persons in the facility at the time of the drill, problems encountered, and whether the fire alarm or smoke detector was operative. Program Director will conduct a monthly review of the fire drill log book to ensure accurate completion of the monthly report. |
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 policy and procedure manual and client records, the facility failed to follow five of the facility ' s specific written procedures for the management of treatment/rehabilitation services in four of seven client records reviewed.
1.The policy and procedure manual stated that the program will obtain a consent for treatment during the intake/admission process.
Client #3 was admitted on October 6, 2023 and was discharged on May 9, 2023. The consent to treatment was signed and dated by the client on January 11, 2023.
2.The policy and procedure manual stated that the program will complete a biopsychosocial evaluation within 15 days of admission.
Client #1 was admitted on January 12, 2023 and was active at the time of inspection. The biopsychosocial evaluation was due no later than January 27, 2023; however, the eval was completed on June 19, 2023.
Client #2 was admitted on March 21, 2023 and was active at the time of inspection. The biopsychosocial evaluation was due no later than April 5, 2023; however, the eval was completed on April 28, 2023.
Client #3 was admitted on October 6, 2022 and discharged on May 9, 2023. The biopsychosocial evaluation was due no later than October 21, 2022; however, the eval was completed on February 15, 2023.
3.The policy and procedure manual stated that the program will complete a comprehensive initial treatment plan within 21 days of admission.
Client #2 was admitted on March 21, 2023 and was active at the time of inspection. The individual treatment and rehabilitation plan was due no later than April 11, 2023; however, the plan was completed on April 22, 2023.
Client #3 was admitted on October 6, 2022 and was discharged on May 9, 2023. The individual treatment and rehabilitation plan was due no later than October 27, 2023; however, the plan was completed on January 19, 2023.
4.The policy and procedure manual stated that the program will begin the aftercare planning at intake and be developed 30 days before discharge.
Client #3 was admitted on October 6, 2022 and was discharged on May 9, 2023. The aftercare plan was due no later than April 9, 2023; however, the plan was completed on July 26, 2023.
Client #5 was admitted on October 26, 2022 and was discharged on March 10, 2023. The aftercare plan was due no later than February 10, 2023; however, the plan was completed on July 26, 2023.
5.The policy and procedure manual stated that the program will complete the discharge summary within one week of discharge.
Client #3 was admitted on October 6, 2022 and was discharged on May 9, 2023. The discharge summary was due no later than May 16, 2023; however, the summary was completed on July 26, 2023.
Client #5 was admitted on October 26, 2022 and was discharged on March 10, 2023. The discharge summary was due no later than March 17, 2023; however, the summary was completed on July 26, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, upon admission, participants will be given a consent for treatment form to complete and sign during their intake process. The remainder of services including biopsychosocial evaluations, comprehensive treatment plan, aftercare plan, and discharge summary will all be completed within the appropriate timeframes.
Clinical Manager will complete weekly chart reviews to ensure that all participants have completed their intake forms, including the consent for treatment form in their intake packet. He will also check that the services provided have been documented in a timely manner, using the appropriate forms. A weekly clinical review will be sent to the Director and Regional Director who will conduct monthly chart audits.
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709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of client records, the facility failed to obtain a written informed and voluntary consent from the client for the disclosure of information contained in the client record in all client records reviewed.
Client #1 was admitted on January 12, 2023 and was active at the time of inspection. There were documentation of disclosures to a urinalysis laboratory on January 30, 2023, March 6, 2023, March 23, 2023, April 10, 2023, April 27, 2023, May 15, 2023 and June 5, 2023; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
Client #2 was admitted on March 21, 2023 and was active at the time of inspection. There were documentation of disclosures to a urinalysis laboratory on April 10, 2023, April 27, 2023, and June 5, 2023; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
Client #3 was admitted on October 6, 2022 and was discharged on May 9, 2023. There were documentation of disclosures to a urinalysis laboratory on October 6, 2022, November 1, 2022, November 25, 2022, November 28, 2022, December 14, 2022, March 23, 2023, April 10, 2023, and April 27, 2023; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
Client #4 was admitted on October 11, 2022 and was discharged on February 8, 2023. There were documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
Client #5 was admitted on October 26, 2022 and was discharged on March 10, 2023. There were documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
Client #6 was admitted on November 3, 2022 and was discharged on December 2, 2023. There were documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
Client #7 was admitted on November 1, 2022 and was discharged on December 21, 2022. There were documentation of disclosures to a urinalysis laboratory on November 12, 2022, November 28, 2022, and December 14, 2022; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
August 11, 2023 staff were retrained to complete release of information forms prior to making any disclosures with outside entities. Clinical Manager will complete weekly chart reviews to ensure consents are completed accurately. A weekly clinical review will be sent to the Director and Regional Director will conduct monthly chart audits. |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom a disclosure was to be made to on release of information forms in three of seven client records reviewed.
Client #3 was admitted on October 6, 2022 and was discharged on May 9, 2023. A blank release of information form was signed and dated by the client on October 10, 2022; however, the name of the person, agency, or organization to whom disclosure was to be made was not included on the form.
Client #4 was admitted on October 11, 2022 and was discharged on February 8, 2023. There were three blank release of information forms signed and dated by the client on October 11, 2022; however, the name of the person, agency, or organization to whom disclosure was to be made was not included on any of the forms.
Client #5 was admitted on October 26, 2022 and was discharged on March 10, 2023. A release of information form to a physician was signed and dated by the client on January 12, 2023; however, the name of the person, agency, or organization to whom disclosure was to be made was not included on the form.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Manager will retrain the clinical staff to include the person, agency or organization to whom a disclosure may be made on the consent form. Clinical Manager will conduct a training with all clinical staff on September 5, 2023 on completion of consents. Clinical Manager will complete weekly chart reviews to ensure consents are completed accurately. A weekly clinical review will be sent to the Director and Regional Director will conduct monthly chart audits. |
709.28 (c) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to document the specific information to be released on consent forms in one of seven client records reviewed.
Client #2 was admitted on March 21, 2023 and was active at the time of inspection. A release of information form to an outside individual was signed and dated by the client on March 21, 2023; however, the specific information to be released documented "only what the resident says can be disclosed", which is not specific enough information to be disclosed pertaining to the purpose. Additionally, a release for information form to a school was signed and dated by the client on March 21, 2023; however, the specific info to be released documented "only pertaining to the child", which is not specific enough information to be disclosed pertaining to the purpose.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Manager will retrain clinical staff to include specific information that may be released when completing the consent form. Clinical Manager will conduct a training with all clinical staff on September 5, 2023 on completion of consents. Clinical Manager will complete weekly chart reviews to ensure consents are completed accurately. A weekly clinical review will be sent to the Director and Regional Director will conduct monthly chart audits. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document dated signature of client on a release of information form in one of seven client records reviewed.
Client #1 was admitted on January 12, 2023 and active at time of inspection. A release of information form to another treatment provider was signed by the client; however, the signature of the client did not include the date the form was signed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director has obtained an updated consent template to include date and signature. This template has been added to the intake packet effective immediately.
Program Director/Clinical Manager will conduct a training with all clinical staff by September 15, 2023 on completion of consents. Clinical Manager will complete weekly chart reviews to ensure consents are completed accurately. A weekly clinical review will be sent to the Director and Regional Director will conduct monthly chart audits.
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709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of client records, the facility failed to document the date, event, or condition upon which the consent will expire in two of seven client records reviewed.
Client #2 was admitted on March 21, 2023 and was active at the time of inspection. A release of information form to an outside individual was signed and dated by the client on March 21, 2023; however, there was no date, event, or condition upon which the consent will expire included on the consent form.
Client #5 was admitted on October 26, 2022 and was discharged on March 10, 2023. There were release of information forms to a government agency, another treatment provider, a urinalysis laboratory, and an emergency contact that were signed and dated by the client on October 26, 2022; however, the date, event, or condition upon which the consent will expire was not included on any of the consent forms.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Manager will retrain clinical staff on how to add the date, event or condition surrounding the expiration on all consent forms.
Clinical Manager will conduct a training with all clinical staff by September 15, 2023 on completion of consents. Clinical Manager will complete weekly chart reviews to ensure consents are completed accurately. A weekly clinical review will be sent to the Director and Regional Director will conduct monthly chart audits.
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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 a review of client records, the facility failed to document that a copy of a client consent form was offered to the client in five of seven client records reviewed.
Client #1 was admitted on January 12, 2023 and was active at the time of inspection. There were release of information forms to a caseworker, an emergency contact, an attorney, and a funding source that were all signed and dated by the client on January 12, 2023; however, there was no documentation that any of the forms were offered to the client.
Client #2 was admitted on March 21, 2023 and was active at the time of inspection. There were release of information forms to a crisis service, a school, and an outside individual that were all signed and dated by the client on March 21, 2023; however, there was no documentation that any of the forms were offered to the client.
Client #3 was admitted on October 6, 2022 and was discharged on May 9, 2023. There were release of information forms to a funding source and a government agency that were signed and dated by the client on October 7, 2022 and release of information forms to a physician, an emergency contact, and a government agency that were signed and dated by the client on January 11, 2023; however, there was no documentation that any of the forms were offered to the client.
Client #4 was admitted on October 11, 2022 and was discharged on February 8, 2023. There was a release of information form to a physician that was signed and dated by the client on December 15, 2022; however, there was no documentation that the form was offered to the client.
Client #5 was admitted on October 26, 2022 and was discharged on March 10, 2023. A release of information form to a government agency was signed and dated by the client on November 1, 2022 and a release of information form to a physician was signed and dated by the client on January 12, 2023; however, there was no documentation that either form was offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Manager will conduct a training with all clinical staff by September 15, 2023, which will consist of ensuring a copy of the consent is offered to the participant at the time of completion of the consent form. Clinical Manager will complete weekly chart reviews to ensure consents are completed accurately. A weekly clinical review will be sent to the Director and Regional Director will conduct monthly chart audits.
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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 include documentation verifying the written acknowledgement by clients that they had been informed of their 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, and reasons for removing sections shall be documented in the record in four of seven client records reviewed.
Client #1 was admitted January 12, 2023 and was active at the time of inspection. The client rights acknowledgement document, in the client record, did not include notification of this regulatory client right.
Client #2 was admitted on March 21, 2023 and was active at the time of inspection. The client rights acknowledgement document, in the client record, did not include notification of this regulatory client right.
Client #6 was admitted on November 3, 2022 and was discharged on December 2, 2022. There was no client rights acknowledgement document, in the client record, at the time of the inspection.
Client #7 was admitted on November 1, 2022 and was discharged on December 21, 2022. There was no client rights acknowledgement document, in the client record, at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately the client rights document will be updated and staff will be trained on the procedures for client rights by September 30, 2023. Clinical Manager will conduct weekly chart reviews to ensure the proper client rights document is completed in each chart. |
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 include documentation verifying the written acknowledgement by clients that they had been informed of their right to appeal a decision limiting access to their records to the director in four of seven client records reviewed.
Client #1 was admitted January 12, 2023 and was active at the time of inspection. The client rights acknowledgement document, in the client record, did not include notification of this regulatory client right.
Client #2 was admitted on March 21, 2023 and was active at the time of inspection. The client rights acknowledgement document, in the client record, did not include notification of this regulatory client right.
Client #6 was admitted on November 3, 2022 and was discharged on December 2, 2022. There was no client rights acknowledgement document, in the client record, at the time of the inspection.
Client #7 was admitted on November 1, 2022 and was discharged on December 21, 2022. There was no client rights acknowledgement document, in the client record, at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately the client rights document will be updated and staff will be trained on the procedures for client rights by September 30, 2023. Clinical Manager will conduct weekly chart reviews to ensure the proper client rights document is completed in each chart. |
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 include documentation verifying the written acknowledgement by clients that they had been informed of their right to request the correction of inaccurate, irrelevant, outdated, or incomplete information in their records in four to seven client records reviewed.
Client #1 was admitted January 12, 2023 and was active at the time of inspection. The client rights acknowledgement document, in the client record, did not include notification of this regulatory client right.
Client #2 was admitted on March 21, 2023 and was active at the time of inspection. The client rights acknowledgement document, in the client record, did not include notification of this regulatory client right.
Client #6 was admitted on November 3, 2022 and was discharged on December 2, 2022. There was no client rights acknowledgement document, in the client record, at the time of the inspection.
Client #7 was admitted on November 1, 2022 and was discharged on December 21, 2022. There was no client rights acknowledgement document, in the client record, at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately the client rights document will be updated and staff will be trained on the procedures for client rights by September 30, 2023. Clinical Manager will conduct weekly chart reviews to ensure the proper client rights document is completed in each chart. |
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 include documentation verifying the written acknowledgement by clients that they had been informed of their right to submit rebuttal data or memoranda to their own records in four of seven client records reviewed.
Client #1 was admitted January 12, 2023 and was active at the time of inspection. The client rights acknowledgement document, in the client record, did not include notification of this regulatory client right.
Client #2 was admitted on March 21, 2023 and was active at the time of inspection. The client rights acknowledgement document, in the client record, did not include notification of this regulatory client right.
Client #6 was admitted on November 3, 2022 and was discharged on December 2, 2022. There was no client rights acknowledgement document, in the client record, at the time of the inspection.
Client #7 was admitted on November 1, 2022 and was discharged on December 21, 2022. There was no client rights acknowledgement document, in the client record, at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately the client rights document will be updated and staff will be trained on the procedures for client rights by September 30, 2023. Clinical Manager will conduct weekly chart reviews to ensure the proper client rights document is completed in each chart. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on review of client records, the facility failed to notify the Department within 3 business days following an event at the facility requiring the presence of police, fire, or ambulance personnel.
On November 14, 2022, emergency medical personnel were called to the facility; however, there was no documentation this incident was reported to the Department within 3 business days.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately the program has implemented the DDAP Incident Reporting process within the program. All staff were trained by Regional Director on how to properly submit state incident reports on August 11, 2023. Program Director has created an incident report log that will be reviewed monthly to make sure all incidents were reported to appropriate agencies in the required time frame. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of client records, the facility failed to include, during the intake and admission process, documentation of a physical exam in seven of seven client records reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, Program Director has added physical form in the Admissions packet. If a participant does not have a copy of a previous physical exam completed within the prior 12 months, a physical will be scheduled with PCP within 48 hours of admission; if the participant cannot be seen within 48 hours, they will be taken to urgent care to have the physical completed.
Clinical Manager will monitor by completing weekly chart reviews to ensure that physicals are complete. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to include documentation of a psychosocial evaluation, during the intake and admission process, in three of seven client records reviewed.
Client #4 was admitted on October 11, 2022 and was discharged on February 8, 2023. There was no psychosocial evaluation, documented in the client record, at the time of inspection.
Client #6 was admitted on November 3, 2022 and was discharged on December 2, 2022. There was no psychosocial evaluation, documented in the client record, at the time of inspection.
Client #7 was admitted on November 1, 2022 and was discharged on December 21, 2022. There was no psychosocial evaluation, documented in the client record, at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, all psychosocial evaluations have been completed and placed in client charts. The participant will complete the psychosocial evaluation within 14 days of admission date.
Clinical Manager will monitor by completing weekly chart reviews to ensure that phychosocials are complete. A weekly review will be conducted by Program Director who will notify Regional Director monthly.
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709.51(b)(7) LICENSURE Preliminary Tx. Plan.
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to include documentation of a preliminary treatment and rehabilitation plan, during the intake and admissions process, in seven of seven client records reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, a treatment plan will be completed within 24 hours of participant's admission.
Clinical Manager will monitor by completing weekly chart reviews to ensure that treatment plans are complete. A weekly review will be conducted by Program Director who will notify Regional Director monthly.
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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 a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in four of five applicable client records reviewed.
Client #1 was admitted on January 12, 2023 and was active at the time of inspection. The individual treatment and rehabilitation plan was completed on January 20, 2023; however, the plan did not include type and frequency of treatment and rehabilitation services.
Client #2 was admitted on March 21, 2023 and was active at the time of inspection. The individual treatment and rehabilitation plan was completed on April 22, 2023; however, the plan did not include the frequency of treatment and rehabilitation services.
Client #3 was admitted on October 6, 2022 and was discharged on May 9, 2023. The individual treatment and rehabilitation plan was completed on January 19, 2023; however, the plan did not include type and frequency of treatment and rehabilitation services.
Client #5 was admitted on October 26, 2022 and was discharged on March 10, 2023. The individual treatment and rehabilitation plan was completed on November 17, 2022; however, the plan did not include type and frequency of treatment and rehabilitation services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will provide training to all clinical staff to include type and frequency of services, which is to be included in the treatment plans by September 30, 2023.
Clinical Manager will review all treatment plans prior to approval to ensure that correct type and frequency of services is appropriately documented.
Clinical Manager will complete weekly chart reviews to ensure the regularities of counseling is provided appropriately.
A weekly review will be conducted by Program Director who will notify Regional Director monthly.
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709.52(a)(3) LICENSURE Support service type
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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document the proposed type of support service on the individual treatment and rehabilitation plan in four of five applicable client records reviewed.
Client #1 was admitted on January 12, 2023 and was active at the time of inspection. The individual treatment and rehabilitation plan was completed on January 20, 2023; however, the plan did not include proposed type of support service.
Client #3 was admitted on October 6, 2022 and was discharged on May 9, 2023. The individual treatment and rehabilitation plan was completed on January 19, 2023; however, the plan did not include proposed type of support service.
Client #5 was admitted on October 26, 2022 and was discharged on March 10, 2023. The individual treatment and rehabilitation plan was completed on November 17, 2022; however, the plan did not include proposed type of support service.
Client #6 was admitted on November 3, 2022 and was discharged on December 2, 2022. The individual treatment and rehabilitation plan was completed on November 22, 2022; however, the plan did not include proposed type of support service.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will provide training to all clinical staff to include proposed type of support service, which is to be included in the treatment plans by September 30, 2023.
Clinical Manager will review all treatment plans prior to approval to ensure that correct proposed type of support service is appropriately documented.
Clinical Manager will complete weekly chart reviews to ensure the regularities of counseling is provided appropriately.
A weekly review will be conducted by Program Director who will notify Regional Director monthly.
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709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to ensure all treatment and rehabilitation plans are reviewed and updated at least every thirty days in four of five applicable client records reviewed.
Client #1 was admitted on January 12, 2023 and was active at the time of inspection. The individual treatment and rehabilitation plan was completed on January 20, 2023, and the first update was due no later than February 20, 2023; however, the update was completed on May 11, 2023. Additionally, a treatment plan update was completed on June 7, 2023, and the next update was due no later than July 7, 2023; however, the update was completed on July 11, 2023.
Client #2 was admitted on March 21, 2023 and was active at the time of inspection. The individual treatment and rehabilitation plan was completed on April 22, 2023, and the first update was due no later than May 22, 2023; however, the update was completed on June 9, 2023.
Client #3 was admitted on October 6, 2022 and was discharged on May 9, 2023. A treatment plan update was completed on February 15, 2023, and the next update was due no later than March 15, 2023; however, the update was completed on March 28, 2023. Additionally, the next treatment plan update was due no later than April 28, 2023; however, the update was completed on May 4, 2023.
Client #5 was admitted on October 26, 2022 and was discharged on March 10, 2023. The individual treatment and rehabilitation plan was completed on November 17, 2022, and the first update was due no later than December 17, 2022; however, the update was completed on January 3, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, the Clinical Manager will run a weekly report in the electronic medical record to identify clients whose treatment plan due to expire within 7 days and coordinate with clinical staff to ensure the treatment plan is updated prior to expiring. A weekly clinical review will be sent to the Director who will conduct on-going monthly chart audits to monitor this process. The clinical team will be retrained in this process by September 30, 2023. |
709.53(a)(8) LICENSURE Case Consultation Notes
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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include case consultation notes, in five of five applicable client records reviewed.
Client #1 was admitted on January 12, 2023 and was active at the time of inspection. There was no documentation of case consultations notes during the treatment episode.
Client #2 was admitted on March 21, 2023 and was active at the time of inspection. There was no documentation of case consultations notes during the treatment episode.
Client #3 was admitted on October 6, 2022 and was discharged on May 9, 2023. There was no documentation of case consultations notes during the treatment episode.
Client #4 was admitted on October 11, 2022 and was discharged on February 8, 2023. There was no documentation of case consultations notes during the treatment episode.
Client #5 was admitted on October 26, 2022 and was discharged on March 10, 2023. There was no documentation of case consultations notes during the treatment episode.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, Case Consultations will be held within the first 90 days of treatment with full treatment team and documented in the clients' chart.
A weekly clinical review will be sent to the Director who will conduct on-going monthly chart audits to monitor this process. The clinical team will be retrained in this process by September 30, 2023.
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709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include follow-up information, in one of two applicable client records reviewed.
Client #3 was admitted on October 6, 2022 and was discharged on May 9, 2023. There was no documentation of follow-up information as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director and Clinical Manager will add the follow-up process to the Aftercare Plans form that will be implemented effective immediately.
Before chart is closed, the Director or Clinical Manager will review the chart to ensure it includes the 7-day follow-up.
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