INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 16, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Lakeside NEPA Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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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 six staff records conducted during the inspection on December 16, 2021, the facility failed to ensure that one staff had the mandatory training in communicable diseases within the required time frames.
Staff #5 was hired as a counselor on September 2, 2020. The staff person was required to have 4 hours of TB/STD training by September 2, 2021, but at the time of the inspection, the staff person had no documentation of training in this area.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
704.11(c)(1) Licensure Mandatory Communicable Disease Training:
The facility failed to comply with regulation 704.11(c)(1) related to the general training requirements for mandatory communicable disease training.
Program Director met with the clinical staff to review required trainings that need to be completed within the guidelines. On 12/27/2021, the Program Director conducted an in-house training to all current employees on HIV and STD/TB. All training certificates have been issues and filed within employee binders.
Completion Date: 12/27/2021
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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 10 fire drill records, the facility failed to maintain a written fire drill record to include whether the smoke detector or fire alarm were operative on June 16, 2021, July 14, 2021, August 9. 2021, October 13, 2021, November 2, 2021 and November 16, 2021.
These findings were discussed with facility staff during the licensing process.
This is a repeat citation from an inspection that took place on February 3, 2021.
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Plan of Correction
705.28(d)(4) Licensure Fire Safety:
The facility failed to comply with regulation 705.28(d)(4) relating to maintaining fire drill records. Based on these findings, Health and Safety Officer has been retrained on properly documenting drills. Program Director will monitor and review fire drill records on a monthly basis to ensure documentation is completed properly.
Completion Date: 12/27/2021
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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 an administrative review of the project's 2020 income tax return, the project failed to provide documentation of an annual financial audit of the activities associated with the project's drug and alcohol abuse services for the project's prior fiscal year.
The findings were discussed with project staff during the licensing process.
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Plan of Correction
709.25 Licensure Fiscal Management:
The facility failed to comply with regulation 709.25 in obtaining services of an independent certified public accountant. All financial audits will be completed by an independent certified public accountant for services for the project's prior fiscal year if revenue exceeds five hundred thousand dollars and will be submitted to the Department of Drug and Alcohol when requested.
A waiver from the independent certified public accountant will be issued for any revenue under five hundred thousand dollars. For the year 2020, the facility did not exceed revenue over five hundred thousand dollars and a waiver was issued and submitted to the Department of Drug and Alcohol on December 16th, 2021. The waiver was accepted and approved by the Department of Drug and Alcohol on December 21,2021. Waiver is on record if requested.
Completion Date: 12/16/2021
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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 seven client records the facility failed to keep information within the limits of 255.5 in all seven records reviewed.
Each client record had a document titled " Release of Medical Information " that included the following statement, " In addition, I authorize Lakeside NEPA, Inc. to disclose any and all written information from the above named to my above named Insurance Company and/or its designated representatives, or other financially responsible party; at the determination of Lakeside NEPA, Inc.. Such disclosure shall be for reimbursement purposes for those services received. "
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
709.28(c)(2) Licensure Confidentiality:
The facility failed to comply with regulation 709.28(c)(2) Confidentiality to keep information within the limits of 255.5 for the disclosure of information contained in the client record. On December 16th, the Program Director revised the Client Rights document in the Electronic Medical Record to include accurate information. Specifically, lines 3,5 and 6 have been updated. The Program Director had the Release of Medical Information Consent removed/deleted. Clinical Staff members have been educated on the updates.
Completion Date: 12/16/2021
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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 seven client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included that a copy of the client consent was offered to the client and a copy maintained in the record.
Client #4 was admitted on July 9, 2021 and was still current at the time of the inspection. A release to the funding source that was signed, dated and witnessed on August 5, 2021 did not indicate if a copy of the client consent was offered to the client.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
709.28(d) Licensure Confidentiality:
The facility failed to comply with regulation 709.28(d) related to Confidentiality in the client record to include that a copy of the client consent was offered to the client and a copy maintained in the record. Based on these findings, the clinical staff have been retrained on the proper way to complete the releases and ensure a copy was offered to the client. The Program Director will review client charts on a weekly basis to assure the releases are completed properly.
Completion Date: 12/27/2021
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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 seven client records on December 16, 2021, the facility failed to document psychosocial evaluations on the first session per the policy and procedure manual in three out of seven applicable records reviewed.
Client #4 was admitted on July 9, 2021 and was still active at the time of the inspection. The psychosocial in the client record was not completed until the second session.
Client #5 was admitted on June 9, 2021 and was discharged on October 27, 2021. The psychosocial in the client record was not completed until the second session.
Client #7 was admitted March 11, 2021 and was discharged on October 4, 2021. The psychosocial in the client record was not completed until the second session.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.91(b)(6) Licensure Intake and Admission:
The facility failed to comply with regulation 709.91(b)(6) in documenting psychosocial evaluation on the first session per the policy and procedure. The facility revised the policy and procedure related to psychosocial completion due date. The revised policy allows for the clients psychosocial to be completed by a clinical staff member within the first thirty days of enrollment into the program.
Completion Date: 12/27/2021
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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 the review of seven client records on December 16, 2021, the facility failed to document type and/or frequency of treatment and rehabilitation services in seven out of seven applicable records reviewed.
Client #1 was admitted on September 17, 2021 and was still active at the time of the inspection. The comprehensive treatment plan and treatment plan updates dated; September 29, 2021, October 28, 2021 and November 29, 2021 did not have type and frequency of treatment and rehabilitation services documented.
Client #2 was admitted on May 27, 2021 and was still active at the time of the inspection. The comprehensive treatment plan and treatment plan updates dated; June 25, 2021, July 23, 2021, August 23, 2021 and October 22, 2021 did not have type and frequency of treatment and rehabilitation services documented.
Client #3 was admitted on August 4, 2021 and was still active at the time of the inspection. The comprehensive treatment plan and treatment plan updates dated; August 24, 2021 and October 26, 2021 did not have type and frequency of treatment and rehabilitation services documented.
Client #4 was admitted on July 9, 2021 and was still active at the time of the inspection. The comprehensive treatment plan and treatment plan updates dated; July 20, 2021, September 9, 2021 and November 9, 2021 did not have type and frequency of treatment and rehabilitation services documented.
Client #5 was admitted on June 9, 2021 and was discharged on October 27, 2021. The comprehensive treatment plan and treatment plan updates dated; August 17, 2021 and October 15, 2021 did not have frequency of treatment and rehabilitation services documented.
Client #6 was admitted on April 30, 2021 and was discharged on June 4, 2021. The comprehensive treatment plan and treatment plan updates dated; April 30, 2021 and May 4, 2021 did not have frequency of treatment and rehabilitation services documented.
Client #7 was admitted on March 11, 2021 and was discharged on October 4, 2021. The comprehensive treatment plan and treatment updates dated; June 22, 2021 and August 23, 2021 did not have frequency of treatment and rehabilitation services documented.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from an inspection that took place on February 3, 2021.
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Plan of Correction
709.92(a)(2) Licensure Treatment and Rehabilitation Services:
The facility failed to comply with regulation 709.92(a)(2) to include type of frequency of treatment and/or rehabilitation services. The clinical staff members have been educated to include the frequency of treatment sessions within each of the client's treatment plans. The Program Director will review and monitor the client's treatment plans to ensure the clinical staff are incorporating the frequency of treatment sessions.
Completion Date: 12/27/2021
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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 on December 16, 2021, the project failed to include follow-up information in one out of three applicable records reviewed.
Client #7 was admitted on March 11, 2021 and was discharged on June 4, 2021. There was no documentation of follow-up information in the client record.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
709.93(a)(11) Licensure Client Record:
The facility failed to comply with regulation 709.93(a)(11) to include discharge follow-up information. Based on these findings, the clinical staff have implemented a tracking tool spreadsheet to assure all discharge follow ups are completed every 30 and 90 days after the client was discharged from the facility. The clinical staff will be completing discharge follow up calls and the Client Discharge Follow Up document in the Electronic Medical Record every 30 and 90 days after the client discharge. The Program Director will monitor the clinical team's spreadsheet during monthly supervision to assure discharge follow up calls and being completed and documented.
Completion Date: 12/27/2021
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