INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 19, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, New Freedom Recovery Center, LLC 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(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of personnel records, the facility failed to provide documentation for any collected feedback from completed trainings in two of two applicable personnel records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On July 25, 2023, the Clinical Supervisor and the Project Manager met with the clinical staff to review training feedback in compliance with 704.11 (a) (3). Starting July 25, 2023, all Clinical Staff have been provided with blank Training Evaluation Forms to be completed with each training. Training Certificates along with the completed Training Evaluation Form will be given to the Compliance Officer. The Compliance Officer will be responsible for maintaining the training certificates and making sure the Training Evaluation form is completed for each training. The Compliance Officer will provide Clinical Staff with Training Evaluation Forms as needed. |
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 obtain an informed and voluntary consent to release information which includes the specific information to be disclosed in one of seven records.
Client #5 was admitted on March 28, 2023 and discharged on June 1, 2023. An informed and voluntary consent dated March 28, 2023 to an attorney did not include specific information to be disclosed.
This is a repeat citation from September 8, 2021 and August 10, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On July 25, 2023, the Human Resource Manager met with the administrative staff responsible for the completion of the consents to release information in accordance with 709.28 (c) (2). The following plan was developed:
1. The Administrative Staff person will be responsible for checking that all consents to release information will be completed in full in compliance with 709.28 (c) (2) during intake of a new client.
2. A weekly meeting will be held with the administrative staff and clinical staff to review that all consents to release information for new clients are completed in full in compliance with 709.28 (c) (2),
3. An acknowledgement page will be added to the client's chart to be initialed by the administration staff person breaking down the chart that the consents to release information have been completed in full in accordance with 709.28 (c) (2), The acknowledgement page will be part of the client's chart.
4. Any additional consents to release information that a client may need during his treatment time will follow the same plan.
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709.28 (c) (3) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent to release information which included the purpose for disclosure in one of seven records.
Client #5 was admitted on March 28, 2023 and discharged on June 1, 2023. An informed and voluntary consent dated March 28, 2023 to an attorney did not indicate the purpose of disclosure.
This is a repeat citation from August 10, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On July 25, 2023, the Human Resource Manager met with the administrative staff responsible for the completion of the consents to release information in accordance with 709.28 (c) (3). The following plan was developed:
1. The Administrative Staff person will be responsible for checking that all consents to release information will be completed in full in compliance with 709.28 (c) (3) during intake of a new client.
2. A weekly meeting will be held with the administrative staff and clinical staff to review that all consents to release information for new clients are completed in full in compliance with 709.28 (c) (3),
3. An acknowledgement page will be added to the client's chart to be initialed by the administration staff person breaking down the chart that the consents to release information have been completed in full in accordance with 709.28 (c) (3), The acknowledgement page will be part of the client's chart.
4. Any additional consents to release information that a client may need during his treatment time will follow the same plan.
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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.
A plan of correction for a consent to release information failing to indicate specific information to be disclosed was submitted and approved by the Department for the September 8, 2021 and August 10, 2022 annual licensing inspections. Consents to release information not indicating the specific information were again found to be a deficiency in the July 19, 2023 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will be responsible for ensuring the plans of corrections are followed so there will be no repeat deficiencies in the future. The Project Director will meet weekly with the clinical and administrative staff to monitor that all plans of corrections are being followed. Chart audits will be performed on all clients on a bi-monthly basis by the clinical staff and reviewed by the Project Director. |