INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 16, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Adappt Outpatient Treatment Services 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in one of two applicable personnel records reviewed.
Employee # 3 was hired as a counselor on January 23, 2023. The HIV/AIDS training and the TB/STD training were due no later than January 23, 2024; however, neither training was completed at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director shall train Facility Director on 704.11, to included requirements of HIV/AIDS and Tuberculosis, STD, and Other Health Related Topics. This will also include requirements of counselors and counselor assistants receiving the training with the first year of employment and all other staff within the first 2 years. The training shall be included in training plans and completion will be reviews monthly be the Facility Director. Project Director shall complete the training by 3/8/24. Counselors will complete training on or before 3/19/24. |
705.28 (d) (2) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(2) Conduct fire drills during normal staffing conditions.
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Observations
Based on a review of the February 2023 through February 2024 fire drill logs, the facility failed to conduct fire drills during normal staffing conditions.
The February 2023 fire drill log documented the drill was conducted at 6:50pm, the June 2023 fire drill log documented the drill was conducted at 6:40pm, the December 2023 fire drill log documented the drill was conducted at 6:30pm, and the January 2024 fire drill log documented the drill was conducted at 6:40pm. However, the fire drills were not conducted during the facility ' s normal staffing conditions as the facility ' s posted hours of operation are Monday and Wednesday from 9:30am to 5:30pm, Tuesday and Thursday from 10:30am to 6:30pm, and Friday from 8:30am to 4:30pm.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Project Director shall train the Facility Director on 705.28 Fire Safety and ensure fire drills are conducted during normal staffing conditions. Project Director shall review the fire logs monthly. The training shall occur by 3/8/24. |
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 facility's February 2023 through February 2024 fire drill logs, the facility failed to ensure that their written fire drill log included the exit route used.
Every fire drill log from February 2023 through February 2024 was missing which exit route was used for each drill.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director shall train the Facility Director on 705.28 Fire safety to ensure a maintained written fire drill record is present. The record shall include 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. Project Director shall review the records monthly. The training shall occur by 3/8/24. |
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 client records, the facility failed to follow three of the project's written procedures for the management of treatment/rehabilitation services in five of seven applicable client records reviewed.
First, the facility policy and procedure manual stated that the psychosocial evaluation is to be completed within thirty days of admission.
Client # 1 was admitted on August 11, 2023 and was still active at the time of the inspection. The psychosocial evaluation was due to be completed by September 11, 2023; however, the evaluation was not completed until December 11, 2023.
Second, the facility policy and procedure manual stated that the preliminary treatment and rehabilitation plan is to be completed at intake.
Client # 5 was admitted on July 17, 2023 and was still discharged on November 15, 2023. The preliminary treatment and rehabilitation plan was due to be completed by July 17, 2023; however, the preliminary treatment plan was not completed until August 21, 2023.
Client # 7 was admitted on November 16, 2023 and was still active at the time of the inspection. The preliminary treatment and rehabilitation plan was due to be completed by November 16, 2023; however, the preliminary treatment plan was not completed until November 29, 2023.
Finally, the facility policy and procedure manual stated that the individual treatment and rehabilitation plan is to be completed within thirty days of admission.
Client # 2 was admitted on November 22, 2023 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by December 22, 2023; however, the treatment plan was not completed until December 27, 2023.
Client # 6 was admitted on August 30, 2023 and was discharged on November 9, 2023. The individual treatment and rehabilitation plan was due to be completed by September 30, 2023; however, the treatment plan was not completed until October 10, 2023.
This is a repeat citation from the February 7, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director and Facility Director shall train staff on 709.24 Treatment/rehabilitation management, specifically the facility policy requiring that the psychosocial evaluation is to be completed within thirty days of admission, the preliminary treatment and rehabilitation plan is to be completed at intake, and the individual treatment and rehabilitation plan is to be completed within thirty days of admission. The Facility Director shall complete two file reviews monthly, per counselor, to ensure compliance. This shall occur by 3/8/24. |
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 complete an informed and voluntary consent to release information form prior to the disclosure of information in one of seven client records reviewed.
Client # 3 was admitted on October 12, 2023 and was still active at the time of the inspection. There was evidence 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 any of the disclosures.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director shall train staff on 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 Facility Director shall complete two file reviews monthly, per counselor, to ensure compliance, including review of counselor notes. Training shall occur by 3/8/24. The client referenced shall have record updated by 3/15/24. |
709.29 (a) LICENSURE Retention of client records
§ 709.29. Retention of client records.
(a) Client records, regardless of format, shall be readily accessible for a minimum of 4 years following the discharge of a client.
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Observations
Based on an administrative review, the facility failed to keep client records readily accessible for a minimum of 4 years following the discharge of a client.
On the date of the inspection, the DDAP representative requested five discharged client records from the discharged client list provided by the facility; however, only four of the discharged client records were located and provided. The facility representative informed the DDAP representative that one discharged client record could not be located.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director shall train Facility Director on record retention requirements. Project Director shall inspect for file accessibility monthly. A minimum of five files will be requested. This shall occur by 3/8/24. |
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 client records, the facility failed to document the written acknowledgement by clients that they have been notified of their regulatory client rights in three of seven client records reviewed.
Client # 1 was admitted on August 11, 2023 and was still active at the time of the inspection. There was no client rights acknowledgement documented in the record at the time of the inspection.
Client # 3 was admitted on October 12, 2023 and was still active at the time of the inspection. There was no client rights acknowledgement documented in the record at the time of the inspection.
Client # 5 was admitted on July 17, 2023 and was still discharged on November 15, 2023. There was no client rights acknowledgement documented in the record at the time of the inspection.
This is a repeat citation from the February 7, 2023 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director shall review written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights with the Facility Director. The Facility Director shall also train counselors and other staff of requirement. The Facility Director shall complete two file reviews monthly, per counselor, to ensure compliance. Training shall occur by 3/8/24. Client rights acknowledgement will be completed by 3/15/24. |
709.92(a)(3) 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:
(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 services on the individual treatment and rehabilitation plan in two of five applicable client records reviewed.
Client # 2 was admitted on November 22, 2023 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on December 27, 2023; however, the plan did not include any proposed type of support services.
Client # 3 was admitted on October 12, 2023 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on November 12, 2023; however, the plan did not include any proposed type of support services.
This is a repeat citation from the February 7, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director shall review requirement for treatment and rehabilitative services, specifically documenting the propose type of support services on the individual treatment and rehabilitation plan with the Facility Director. Facility Director shall train counselors and other staff. The Facility Director shall complete two file reviews monthly, per counselor, to ensure compliance. Training shall occur by 3/8/24. Client records to included types of support services on the individual treatment and rehabilitation plan shall be completed by 3/15/24. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to assure that counseling services were provided according to the individual treatment and rehabilitation plan in two of five client records reviewed.
Client # 2 was admitted on November 22, 2023 and was still active at the time of the inspection. The individual treatment and rehabilitation plan, completed on December 27, 2023, and treatment plan updates completed on January 27, 2024 and February 15, 2024, indicated the client was to receive one individual counseling session per week. The client's progress notes indicated that the client had received only one individual counseling session during the months of November 2023, December 2023, and January 2024.
Client # 3 was admitted on October 12, 2023 and was still active at the time of the inspection. The individual treatment and rehabilitation plan, completed on November 12, 2023, and treatment plan updates, completed on December 19, 2023 and January 16, 2024, indicated the client was to receive one individual counseling session per week. The client's record of service and progress notes indicated that the client had received only one individual session during the months of October 2023, November 2023, and February 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director shall review requirement for treatment and rehabilitative services, specifically that counseling services are provided according to the individual treatment and rehabilitation plan and documenting in the client records with the Facility Director. Facility Director shall train counselors and other staff to complete these requirements. The Facility Director shall complete two file reviews monthly, per counselor, to ensure compliance. Training shall occur by 3/8/24. All active files shall be corrected by the counselors by 3/15/24. |
709.93(a)(3) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(3) Record of services provided.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include a completed record of services provided, in five of seven client records reviewed.
Client # 2 was admitted on November 22, 2023 and was still active at the time of the inspection. There was no record of service documented in the record at the time of the inspection.
Client # 3 was admitted on October 12, 2023 and was still active at the time of the inspection. The progress notes in the record indicated that counseling services were provided on October 25, 2023, October 26, 2023, November 2, 2023, November 9, 2023, January 11, 2024, January 18, 2024, January 25, 2024, February 1, 2024, February 8, 2024, and February 15, 2024; however, none of these sessions were documented on the record of service.
Client # 4 was admitted on July 7, 2023 and was discharged on December 21, 2023. The progress notes in the record indicated that a counseling session was provided on July 27, 2023; however, the session was not documented on the record of service.
Client # 6 was admitted on August 30, 2023 and was discharged on November 9, 2023. The progress notes in the client record at the time of the inspection indicated that counseling services were provided on September 26, 2023, September 28, 2023, October 3, 2023, October 5, 2023, October 12, 2023, October 17, 2023, October 19, 2023, October 24, 2023, October 26, 2023, October 31, 2023, November 2, 2023, and November 7, 2023; however, none of these sessions were documented on the record of service.
Client # 7 was admitted on November 16, 2023 and was still active at the time of the inspection. The progress notes in the client record at the time of the inspection indicated that counseling services were provided on November 30, 2023, December 28, 2023, January 3, 2024, January 11, 2023, January 18, 2024, January 25, 2024, February 1, 2024, February 8, 2024, February 14, 2024, and February 15, 2024; however, none of these sessions were documented on the record of service.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director shall review requirement for completing client record on an individual which includes information relative to the client's involvement with the project, including, but not limited to, a record of services provided with the Facility Director. Facility Director shall train counselors and other staff to complete these requirements. The Facility Director shall complete two file reviews monthly, per counselor, to ensure compliance. Training shall occur by 3/8/24. All active files shall be corrected by the counselors by 3/15/24. |
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 maintain a complete client record, which is to include progress notes, in five of seven client records reviewed.
Client # 1 was admitted on August 11, 2023 and was still active at the time of the inspection. The record of service indicated that counseling sessions were provided on October 26, 2023, December 18, 2023, December 19, 2023, January 4, 2024, January 8, 2024, January 11, 2024, January 18, 2024, January 23, 2024, January 24, 2024, January 29, 2024, February 7, 2024, and February 16, 2024; however, there were no progress notes documented in the record at the time of the inspection.
Client # 3 was admitted on October 12, 2023 and was still active at the time of the inspection. The record of service indicated that counseling sessions were provided on October 12, 2023 and November 6, 2023; however, there were no progress notes documented in the record at the time of the inspection.
Client # 4 was admitted on July 7, 2023 and was discharged on December 21, 2023. The record of service indicated that counseling sessions were provided on August 2, 2023 and July 12, 2023; however, there were no progress notes documented in the record at the time of the inspection.
Client # 6 was admitted on August 30, 2023 and was discharged on November 9, 2023. The record of service indicated that counseling sessions were provided on September 19, 2023, September 22, 2023, October 3, 2023, and October 4, 2023; however, there were no progress notes documented in the record at the time of the inspection.
Client # 7 was admitted on November 16, 2023 and was still active at the time of the inspection. The record of service indicated that counseling sessions were provided on December 6, 2023, December 13, 2023, December 14, 2023, December 19, 2023, December 20, 2023, December 26, 2023, January 4, 2024, January 7, 2024, January 8, 2024, January 10, 2024, January 24, 2024, and January 31, 2024; however, there were no progress notes documented in the 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
Project Director shall review requirement for completing client record on an individual which includes information relative to the client's involvement with the project, specifically, progress notes with the Facility Director. Facility Director shall train counselors and other staff to complete these requirements. The Facility Director shall complete two file reviews monthly, per counselor, to ensure compliance. Training shall occur by 3/8/24. All active files shall be corrected by the counselors by 3/15/24. |
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 maintain a complete client record, which is to include case consultation notes, in three of five applicable client records reviewed.
Client # 1 was admitted on August 11, 2023 and was still active at the time of the inspection. There were no case consultation notes documented in the record at the time of the inspection.
Client # 3 was admitted on October 12, 2023 and was still active at the time of the inspection. There were no case consultation notes documented in the record at the time of the inspection.
Client # 5 was admitted on July 17, 2023 and was still discharged on November 15, 2023. There were no case consultation notes documented in the record at the time of the inspection.
This is a repeat citation from the February 7, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director shall review requirement for completing client record on an individual which includes information relative to the client's involvement with the project, specifically, case consultation notes with the Facility Director. Facility Director shall train counselors and other staff to complete these requirements. The Facility Director shall complete two file reviews monthly, per counselor, to ensure compliance. Training shall occur by 3/8/24. All active files shall be addressed by the counselors by 3/15/24. |
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 maintain a complete client record, which is to include a discharge summary, in one of three applicable client records reviewed.
Client # 5 was admitted on July 17, 2023 and was still discharged on November 15, 2023. There was no discharge summary in the 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
Project Director shall review requirement for completing client record on an individual which includes information relative to the client's involvement with the project, specifically, to include the discharge summary with the Facility Director. Facility Director shall train counselors and other staff to complete this requirement. The Facility Director shall complete two file reviews monthly, per counselor, to ensure compliance. Training shall occur by 3/8/24. All active files shall be addressed by the counselors by 3/15/24. |
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 maintain a complete client record, which is to include follow-up information, in three of three applicable client records reviewed.
Client # 4 was admitted on July 7, 2023 and was discharged on December 21, 2023. There was no follow-up information in the record at the time of the inspection.
Client # 5 was admitted on July 17, 2023 and was still discharged on November 15, 2023. There was no follow-up information in the record at the time of the inspection.
Client # 6 was admitted on August 30, 2023 and was discharged on November 9, 2023. There was no follow-up information in the record at the time of the inspection.
This is a repeat citation from the February 22, 2017, May 8, 2018, January 14, 2019, February 13, 2020, February 25, 2021, February 17, 2022, and February 7, 2023 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director shall review requirement for completing client record on an individual which includes information relative to the client's involvement with the project, specifically, to complete Follow-Up post discharge with the Facility Director. Facility Director shall train counselors and other staff to complete this requirement. The Facility Director shall complete two file reviews monthly, per counselor, to ensure compliance. Training shall occur by 3/8/24. All discharged client's files in list 60 days shall be addressed by the counselors by 3/15/24. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
Plans of correction for the documentation of follow-up information were submitted and approved by the Department for the February 22, 2017, May 8, 2018, January 14, 2019, February 13, 2020, February 25, 2021, February 17, 2022, and February 7, 2023 annual licensing inspections. Not documenting follow-up information was again found to be a deficiency in the February 16, 2024 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director and Project Director shall administer training with all new and current staff, focusing on continued deficiencies and soliciting feedback towards any operational changes that can be made to improve compliance. Facility Director shall increase the volume of observation and fill review to improve identifying non-compliance. Facility Director and counselor will correct all fills currently impacted by non-compliance. Project Director shall review policy for opportunities to improve practices. Project Director shall provide quarterly observation of files to further assist quality assurance. This plan shall begin 3/19/24. |