INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 20, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, MCP/Caring Together 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(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to document an annual written individual training plan for each employee, appropriate to that employee's skill level and with input from both the employee and the supervisor, in five of five personnel records reviewed.Employee #1 was hired as the Project Director on January 23, 2017. The last individual training plan documented in the personnel record was completed on May 27, 2020. Employee #2 was hired as a counselor on December 7, 2015. The last individual training plan documented in the personnel record was completed on May 20, 2020. Employee #3 was hired as a counselor on July 6, 2017. The last individual training plan documented in the personnel record was completed on May 20, 2020. Employee #4 was hired as a counselor on December 20, 2019. The last individual training plan documented in the personnel record was completed on May 27, 2020. Employee #5 was hired as a counselor on January 1, 2020. There was no individual training plan documented in the personnel record at the time of the inspection. This is a repeat citation from the April 8, 2021 annual licensing renewal inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Individual Training Plans will be completed by the end of June for all employees. The training plans will be devised during supervision sessions with input from the employee and supervisor. The Individual Training Plans will be submitted to the Medical Director to ensure that the supervisor that completion is occurring in a timely manner. |
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 the review of the Staffing Requirements Facility Summary Report and personnel records, the facility failed to ensure that staff persons and volunteers received a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics within the regulatory timeframes in one of one applicable personnel record reviewed. Employee #5 was hired as a Child Development Specialist on September 10, 2018 and was due to receive the HIV/AIDS training no later than September 10, 2020; however, there was no documentation of the completion of the HIV/AIDS training at the time of the inspection.The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Program Director has ensured that the staff has engaged in the mandatory DDAP trainings. The Program Director obtains the certificates after the completion of all trainings. The copies of the certificates will be stored in the training manual and the employees' personnel files.
The Program Director has Employee #5's certificate of the HIV/AIDS training. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to ensure that each counselor completed at least 25 clock hours of training annually during the facility's July 1, 2020 through June 30, 2021 training year in two of five personnel records reviewed.Employee #2 was hired as a counselor on December 7, 2015. The personnel record documented 20.25 hours of training received during the reviewed training year.Employee #5 was hired as a counselor on January 1, 2020. The personnel record documented 0 hours of training received during the reviewed training year.This is a repeat citation from the April 17, 2019 and April 8, 2021 annual licensing renewal inspections.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director has mandated counselors to engage in training at least once a month. Program Director is responsible for sending training announcements to counselors and notifying if the training is mandatory or elective. The completed trainings are looked on a spreadsheet that is reviewed quarterly during supervision with the counselor.
Progress of staff training's is reviewed quarterly with the Program Director and Medical Director. |
711.17(a)(3) LICENSURE Subchapter B.Approval Procedures.Refusal or
711.17. Refusal or revocation.
(a) The Department may revoke or refuse to issue a certificate of compliance 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 ensuring counselors receive at least 25 clock hours of training annually were submitted and approved by the Department for the April 17, 2019 and April 8, 2021 annual licensing inspections. The 25 clock hours of training annually for counselors were again found to be a deficiency in the April 20, 2022, licensing inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director has mandated counselors to engage in training at least once a month. Program Director is responsible for sending training announcements to counselors and notifying if the training is mandatory or elective. The completed trainings are looked on a spreadsheet that is reviewed quarterly during supervision with the counselor.
Progress of staff training's is reviewed quarterly with the Program Director and Medical Director. This review will occur during Program Director's supervision session. |
711.92(a)(3) LICENSURE Mngt of Treatment Services
711.92. Treatment and rehabilitation services.
(a) The project 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 development, approval and ongoing management of treatment/rehabilitation services for clients.
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Observations
Based on review of client records and the policy and procedure manual, the facility failed to follow the project's written procedures for the development, approval and ongoing management of treatment/rehabilitation services in three of seven client records reviewed.The policy and procedure manual stated that the initial individual rehabilitation and treatment plan would be developed within a month after the initial visit. Client #1 was admitted on June 14, 2021 and was active at the time of inspection. The comprehensive treatment plan was due no later than July 14, 2021; however, the plan was signed and completed by the counselor on January 6, 2022.Client #2 was admitted on June 10, 2021 and was active at the time of inspection. The comprehensive treatment plan was due no later than July 10, 2021; however, the plan was signed and completed by the counselor on August 18, 2021.Client #4 was admitted on August 10, 2021 and was discharged on February 9, 2022. The comprehensive treatment plan was due no later than September 10, 2021; however, the plan was signed and completed by the counselor on September 14, 2021.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment Plans were late for clients cited due to difficulties of telehealth. Inconsistency with with engagement by clients due to lack of lack of operational devices attributed to this issue.
The additional of a new Electronic Medical Record will provide notice to Program Director of due dates for treatment plans. During supervision sessions, Program Director will be able to discuss upcoming due dates for treatment plans and aid counselor in scheduling completion of documentation in a timely manner. |
711.92(c) LICENSURE Individual TX Plan
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to develop and document the individual's comprehensive treatment and rehabilitation plan with the client in all seven client records reviewed.Client #1 was admitted on June 14, 2021 and was active at the time of inspection. The comprehensive treatment plan was signed and dated by facility staff on January 6, 2022; however, there was no written documentation that the plan was developed with the client's input. Client #2 was admitted on June 10, 2021 and was active at the time of inspection. The comprehensive treatment plan was signed and dated by facility staff on August 18, 2021; however, there was no written documentation that the plan was developed with the client's input. Client #3 was admitted on June 15, 2021 and was active at the time of inspection. The comprehensive treatment plan was not developed at the time of inspection. Client #4 was admitted on August 10, 2021 and was discharged on February 9, 2022. The comprehensive treatment plan was signed and dated by facility staff on September 14, 2021; however, there was no written documentation that the plan was developed with the client's input. Client #5 was admitted on August 16, 2021 and was discharged on February 17, 2022. The comprehensive treatment plan was signed and dated by facility staff on September 16, 2021; however, there was no written documentation that the plan was developed with the client's input.Client #6 was admitted on August 18, 2021 and was discharged on November 1, 2021. The comprehensive treatment plan was not developed at the time of inspection. Client #7 was admitted on June 21, 2021 and was discharged on November 10, 2021. The comprehensive treatment plan was not developed at the time of inspection. This is a repeat citation from the April 8, 2021 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment Plans were late for clients cited due to difficulties of telehealth. Inconsistency with with engagement by clients due to lack of lack of operational devices attributed to this issue.
Treatment Plans that are devised/reviewed with clients via telehealth must have notation of the the mode of delivery of service. Program Director has reviewed the necessity of noting that this activity occurred on the treatment plan. Program Director will review treatment plans for this notation.
The additional of a new Electronic Medical Record will provide notice to Program Director of due dates for treatment plans. During supervision sessions, Program Director will be able to discuss upcoming due dates for treatment plans and aid counselor in scheduling completion of documentation in a timely manner.
Staff will be encouraged to utilize a spreadsheet with due dates of treatment plans. Upon completing a tretment plan, the counselor will automatically provide the client with a tentative session date for the completion of the next treatment plan.
During supervision sessions with the counselor, the Program Director will review treatment plans and the date of the next scheduled session of the future plan.
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711.92(d) LICENSURE Tx Plan Update
711.92. Treatment and rehabilitation services.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to ensure that treatment and rehabilitation plans are reviewed and updated at least every sixty days in two of four applicable client records reviewed.Client #2 was admitted on June 10, 2021 and was still active at the time of inspection. The comprehensive treatment plan was completed on August 18, 2021, and the first update was due no later than October 18, 2021; however, the update was completed on October 22, 2021. The next update was due no later than December 22, 2021; however, the update was completed on January 12, 2022. Additionally, the next update was due no later than March 12, 2022; however, the update was not completed at the time of inspection.Client #5 was admitted on August 16, 2021 and was discharged on February 17, 2022. The comprehensive treatment plan was completed September 16, 2021, and the first update was due no later than November 16, 2021; however, the update was completed on November 23, 2021.This is a repeat citation from the April 8, 2021 annual licensing renewal inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment Plans were late for clients cited due to difficulties of telehealth. Inconsistency with with engagement by clients due to lack of lack of operational devices attributed to this issue.
Treatment Plans that are devised/reviewed with clients via telehealth must have notation of the the mode of delivery of service. Program Director has reviewed the necessity of noting that this activity occurred on the treatment plan. Program Director will review treatment plans for this notation.
The additional of a new Electronic Medical Record will provide notice to Program Director of due dates for treatment plans. During supervision sessions, Program Director will be able to discuss upcoming due dates for treatment plans and aid counselor in scheduling completion of documentation in a timely manner. |
711.92(e) LICENSURE Provision of TX RE: TX Plan
711.92. Treatment and rehabilitation services.
(e) 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 ensure that counseling services were being provided according to the individual treatment and rehabilitation plan in five of seven client records reviewed. Client #1 was admitted on June 14, 2021 and was active at the time of inspection. The preliminary treatment plan dated June 14, 2021, specified weekly individual counseling sessions and three groups per week and there was no documentation in the record of individual counseling sessions or group sessions occurring the weeks of July 11, 2021 - July 31, 2021, August 15, 2021 - August 21, 2021, August 29, 2021 - September 25, 2021, October 10, 2021 - November 13, 2021, and November 21, 2021 - January 1, 2022. Additionally, the comprehensive treatment plan dated January 6, 2022, specified weekly individual counseling sessions and there was no documentation in the record of individual counseling sessions occurring the weeks of January 16, 2022 - February 5, 2022, February 13, 2022 - February 26, 2022, and March 6, 2022 - March 19, 2022. Client #2 was admitted on June 10, 2021 and was active at the time of inspection. The comprehensive treatment plan dated August 18, 2021, and treatment plan updates dated October 22, 2021 and January 12, 2022, all specified weekly individual counseling sessions and three groups per week. There was no documentation in the record of individual counseling sessions occurring the weeks of September 5, 2021 - October 2, 2021. Additionally, there was no documentation in the record of group counseling sessions occurring the weeks of August 15, 2021 - April 16, 2022. Client #3 was admitted on June 15, 2021 and was active at the time of inspection. A treatment plan update dated January 20, 2022, specified weekly counseling sessions and three groups per week. There was no documentation in the record of individual counseling sessions and group sessions occurring the weeks of January 30, 2022 - February 19, 2022.Client #4 was admitted on August 10, 2021 and was discharged on February 9, 2022. The preliminary treatment plan dated August 10, 2021, the comprehensive treatment plan dated September 14, 2021, and a treatment plan update dated November 15, 2021, all specified weekly counseling sessions and three groups per week. There was no documentation in the record of group sessions occurring the weeks of August 15, 2021 - January 1, 2022. Client #6 was admitted on August 18, 2021 and was discharged on November 1, 2021. The preliminary treatment plan dated August 18, 2021, specified weekly counseling sessions and three groups per week. There was no documentation in the record of individual counseling sessions and group sessions occurring the weeks of August 22, 2021 - October 23, 2021. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment Plans were late for clients cited due to difficulties of telehealth. Inconsistency with with engagement by clients due to lack of lack of operational devices attributed to this issue.
Treatment Plans that are devised/reviewed with clients via telehealth must have notation of the the mode of delivery of service. Program Director has reviewed the necessity of noting that this activity occurred on the treatment plan. Program Director will review treatment plans for this notation.
Counselors have been informed of the need to note the progress or lack of progress on the treatment plan. Counselors will monitor/review treatment plans with clients to ensure that engagement is occuring. Counselors will address with clients barriers to engaging in treatment as noted in the plans. Adjustments in treatment schedule will occur if warranted and noted in the revised treatment plan.
The additional of a new Electronic Medical Record will provide notice to Program Director of due dates for treatment plans. During supervision sessions, Program Director will be able to discuss upcoming due dates for treatment plans and aid counselor in scheduling completion of documentation in a timely manner. |
711.93(a)(2) LICENSURE Record of Services Provided
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes all information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(2) Record of services provided.
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Observations
Based on a review of client records, the facility failed to document a record of services provided in the complete client record in four of seven client records reviewed. Client #2 was admitted on June 10, 2021 and was active at the time of inspection. There was no record of services documented in the record as of the date of the inspection. Client #5 was admitted on August 16, 2021 and was discharged on February 17, 2022. There was no record of services documented in the record as of the date of the inspection.Client #6 was admitted on August 18, 2021 and was discharged on November 1, 2021. There was no record of services documented in the record as of the date of the inspection.Client #7 was admitted on June 21, 2021 and was discharged on November 10, 2021. There was no record of services documented in the record as of the date of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A new Electronic Medical Record (EMR) is scheduled to go live effective August 9, 2022. The EMR will have an electronic log of all services. Staff will begin engaging in training for the EMR effective June 2022.
Prior to the start of the new EMR, staff have been directed to complete the service log upon completing of all engagement.
Program Director will monitor this task during review of records.
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711.93(a)(6) LICENSURE Aftercare Plans
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(6) Aftercare plans, if applicable.
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Observations
Based on a review of client records, the facility failed to document an aftercare plan in the complete client record in two of two applicable client records reviewed. Client #6 was admitted on August 18, 2021 and was discharged on November 1, 2021. There was no documentation of an aftercare plan in the record as of the date of the inspection. Client #7 was admitted on June 21, 2021 and was discharged on November 10, 2021. There was no documentation of an aftercare plan in the record as of the date of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Training for Aftercare Plans will be scheduled once the document is devised in the new EMR. The Program Director is working with the EMR team to ensure that the newly devised Aftercare Plan has the necessary components.
Until the inception of the new EMR, staff will submit the completed Aftercare Plan to the Program Director with the Discharge Plan for review by the Program Director. |
711.93(a)(7) LICENSURE Follow-up Information
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(7) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow up information in the complete client record in three of four applicable client records reviewed. Client #4 was admitted on August 10, 2021 and was discharged on February 9, 2022. There was no follow-up information documented in the record as of the date of the inspection. Client #5 was admitted on August 16, 2021 and was discharged on February 17, 2022. There was no follow-up information documented in the record as of the date of the inspection.Client #7 was admitted on June 21, 2021 and was discharged on November 10, 2021. There was no follow-up information documented in the record as of the date of the inspection.This is a repeat citation from the April 8, 2021 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Training for Follow-up will be scheduled once the document is devised in the new EMR. The Program Director is working with the EMR team to ensure that the newly devised Follow-up document has the necessary components. The new EMR is scheduled to go live on August 9, 2022.
Prior to August 9, 2022, staff are to complete the follow-up note and submit to the Program Director for review. Charts will not be considered completed without the follow-up note.
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711.93(c)(1)(i) LICENSURE Confidentiality - Client Identity/Records
711.93. Client records.
(c) Confidentiality.
(1) A written procedure shall be developed by the project director which complies with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(i) Confidentiality of client identity and records.
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Observations
Based on a physical plant inspection, the facility failed to maintain the confidentiality of client identity and records by not securing the facility ' s chart room. At the time of the inspection, the chart room was unlocked and was not occupied by appropriate staff persons and there were several client records that were not locked in secured storage containers.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff have been counseled regarding the storage of clients' records. All clinical staff have keys to the chart room and there is no reason leave the chart room unlocked. We discussed the importance of confidentiality.
The new EMR will be secured and the clients' records will be stored electronically. The go live date for the new EMR is August 9, 2022. All staff will engage in confidentiality of EMR prior to the go live date.
The Program Director is responsible for ensuring that the corrective action is implemented and will continue to monitor. |
711.93(c)(2) LICENSURE Consent to Release-Informed & Voluntary
711.93. Client records.
(c) Confidentiality.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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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 two of seven client records reviewed.Client #3 was admitted on June 15, 2021 and was active at the time of inspection. There was documentation of a disclosure to a pharmacy on October 26, 2021; however, there was no consent to release information form signed by the client documented in the record prior to the disclosure.Client #4 was admitted on August 10, 2021 and was discharged on February 9, 2022. There was documentation of a disclosure to a recovery house on October 6, 2021; however, there was no consent to release information form signed by the client documented in the record prior to the disclosure. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Training for the completion of all Release of Information Forms will occur in June 2022. This training will will be documented and all new staff will participate in the training. The training will highlight the need for noting whom the information is disclosed to, contact information and the appropriate signatures. Training will note the inappropriateness of blank/uncompleted forms. The training will include the need to review the clients' chart for a completed Release of Information prior to disclosure.
The Program Director will review Release of Information Forms during the initial chart review within the first 30 days of admission. Program Director will monitor the charts for blank forms.
The Medical Director will review the training log managed by the Program Director for all staff to ensure that engagement has occurred. |
711.93(c)(2)(i) LICENSURE Name of person/agency/organization
711.93. Client records.
(c) Confidentiality.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(i) The 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 two of seven client records reviewed.Client #2 was admitted on June 10, 2021 and was active at the time of inspection. The client record contained a release of information form to the emergency contact that was signed and dated by the witness on June 29, 2021, but the form did not document the name of the person, agency, or organization to whom the disclosure was to be made. Additionally, there were three blank release of information forms signed and dated by the witness on June 29, 2021, but the forms did not document the name of the person, agency, or organization to whom the disclosures were to be made. Client #7 was admitted on June 21, 2021 and was discharged on November 10, 2021. There was a blank release of information form signed and dated by the witness on June 21, 2021, but the form did not document the name of the person, agency, or organization to whom the disclosure was to be made.This is a repeat citation from the April 8, 2021 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will engage in training by the end of June 2022 to address the appropriate completion of the Release of Information (ROIs) Forms. The training will include directives to identify the person and organization, along with contact information of the receiver that will be receiving the information. Staff will be trained to obtain all necessary signatures and dates on the forms. Staff will also be trained to ensure that there are signed ROIs, prior to releasing information.
Program Driector will monitor the charts for completed ROIs during an initial review that occurs after the comopletion of the intake process. Charts will be reviewed every 90 days during a supervision session with the counselor and Program Director.
Current charts will be reviewed to ensure that current ROIs are completed as noted above. |
711.93(c)(2)(ii) LICENSURE Specific Info. Disclosed
711.93. Client records.
(c) Confidentiality.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(ii) The 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 disclosed on release of information forms in six of seven client records reviewed. Client #1 was admitted on June 14, 2021 and was active at the time of inspection. The client record contained a release of information form to the emergency contact that was signed and dated by the client on June 14, 2021, but the form did not document the specific information to be disclosed.Client #2 was admitted on June 10, 2021 and was active at the time of inspection. The client record contained a release of information form to the emergency contact that was signed and dated by the client on June 29, 2021, but the form did not document the specific information to be disclosed.Client #3 was admitted on June 15, 2021 and was active at the time of inspection. The client record contained a release of information form to the emergency contact that was signed and dated by the client on June 15, 2021, but the form did not document the specific information to be disclosed.Client #4 was admitted on August 10, 2021 and was discharged on February 9, 2022. The client record contained a release of information form to the emergency contact that was signed and dated by the client on August 10, 2021, but the form did not document the specific information to be disclosed.Client #5 was admitted on August 16, 2021 and was discharged on February 17, 2022. The client record contained a release of information form to the emergency contact that was signed and dated by the client on August 16, 2021, but the form did not document the specific information to be disclosed.Client #7 was admitted on June 21, 2021 and was discharged on November 10, 2021. The client record contained a release of information form to the emergency contact that was signed and dated by the client on June 21, 2022, but the form did not document the specific information to be disclosed.This is a repeat citation from the April 8, 2021 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Training for the completion of all Release of Information Forms will occur in June 2022. This training will will be documented and all new staff will participate in the training. The training will highlight the need for noting whom the information is disclosed to, contact information and the appropriate signatures.The Release of Information Form for the Emergency Contact is being revised by the Program Director. The revised form will note specific information to be disclosed. The electronic version of the form will have hard stops that must have the required information completed.
The Program Director will review Release of Information Forms during the initial chart review within the first 30 days of admission.
The Medical Director will review the training log managed by the Program Director for all staff to ensure that engagement has occurred. |
711.93(c)(2)(iv) LICENSURE Signature Client/Guardian
711.93. Client records.
(c) Confidentiality.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(iv) The dated signature of the client or guardian.
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Observations
Based on a review client records, the facility failed to document the dated signature of the client on release of information forms in three of seven client records reviewed.Client #2 was admitted on June 10, 2021 and was active at time of inspection. There was a release of information form to an emergency contact that was signed and dated by the witness on June 29, 2021; however, the dated signature of the client was not documented. Additionally, there were three blank release of information forms that were all signed and dated by the witness on June 29, 2021; however, the dated signature of the client was not documented on any of the releases. Also, there was a release of information form to a transportation service that was signed and dated by the witness on June 29, 2021; however, the dated signature of the client was not documented. Client #3 was admitted on June 15, 2021 and was active at time of inspection. There was a release of information form to a hospital that was signed and dated by the witness on July 14, 2021; however, the dated signature of the client was not documented.Client #7 was admitted on June 21, 2021 and was discharged on November 10, 2021. There was a release of information form to an emergency contact that had a future date. The dated signature of the client was June 21, 2022. Additionally, there was a blank release of information form that was signed and dated by the witness on June 21, 2021; however, the dated signature of the client was not documented.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Training for the completion of all Release of Information Forms will occur in June 2022. This training will will be documented and all new staff will participate in the training. The training will highlight the need for noting whom the information is disclosed to, contact information and the appropriate signatures. Training will note the inappropriateness of blank/uncompleted forms.
The Program Director will review Release of Information Forms during the initial chart review within the first 30 days of admission. Program Director will monitor the charts for blank forms.
The Medical Director will review the training log managed by the Program Director for all staff to ensure that engagement has occurred. |
711.93(c)(2)(v) LICENSURE Signature of Witness
711.93. Client records.
(c) Confidentiality.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(v) The dated signature of a witness.
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Observations
Based on a review of client records, the facility failed to document dated signature of witness on release of information forms in one of seven client records reviewed.Client #7 was admitted on June 21, 2021 and was discharged on November 10, 2021. There was a release of information form to an emergency contact that had a future date. The dated signature of the witness was June 21, 2022.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Training for the completion of all Release of Information Forms will occur in June 2022. This training will will be documented and all new staff will participate in the training. The training will highlight the need for noting whom the information is disclosed to, contact information and the appropriate signatures. Training will note the importance of signing and dating the forms.
The Program Director will review Release of Information Forms during the initial chart review within the first 30 days of admission. Program Director will monitor the charts for blank forms.
The Medical Director will review the training log managed by the Program Director for all staff to ensure that engagement has occurred. |
711.93(c)(3) LICENSURE Copy-Client Consent
711.93. Client records.
(c) Confidentiality.
(3) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
Based on a review of client records, the facility failed to document that a copy of a client consent to release information form was offered to the client in four of seven client records reviewed. Client #2 was admitted on June 10, 2021 and was active at the time of inspection. A release of information form to an emergency contact was signed and dated by the witness on June 29, 2021, but there was no documentation that a copy of the form was offered to the client. Additionally, three blank release of information forms were signed and dated by the witness on June 29, 2021, but there was no documentation that a copy of the forms were offered. Additionally, a release of information form to a transportation service was signed and dated by the witness on June 29, 2021, but there was no documentation that a copy of the form was offered to the client.Client #3 was admitted on June 15, 2021 and was active at the time of inspection. A release of information form to a hospital was signed and dated by the witness on July 14, 2021, but there was no documentation that a copy of the form was offered to the client. Client #5 was admitted on August 16, 2021 and was discharged on February 17, 2022. There were release of information forms to the funding source, managed care organization, transportation service, urinalysis laboratory, pharmacy, and physician that were all signed and dated by the client on August 16, 2021, but there was no documentation that a copy of any of the forms were offered to the client. Additionally, a release of information form to a court was signed and dated by the client on December 1, 2021, but there was no documentation that a copy of the form was offered to the client.Client #7 was admitted on June 21, 2021 and was discharged on November 10, 2021. A blank release of information form was signed and dated by the witness on June 21, 2021, but there was no documentation that a copy of the form was offered to the client. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Training for the completion of all Release of Information Forms will occur in June 2022. This training will will be documented and all new staff will participate in the training. The training will highlight the need for noting whom the information is disclosed to, contact information and the appropriate signatures. Training will note the inappropriateness of blank/uncompleted forms. Training will include the need to offer a copy of the form and check the appropriate box noting that the offer was made to the client.
The Program Director will review Release of Information Forms during the initial chart review within the first 30 days of admission. Program Director will monitor the charts for blank forms.
The Medical Director will review the training log managed by the Program Director for all staff to ensure that engagement has occurred. |
711.95(b) LICENSURE Efficient Retrieval of Data
711.95. Uniform Data Collection System.
(b) A data collection system shall be developed that allows for the efficient retrieval of data needed to measure the project's performance.
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Observations
Based on an administrative review, the facility failed to maintain a data collection system that allows for the efficient retrieval of data needed to measure the project's performance.The facility was unable to produce client records in an efficient manner after the DDAP representative requested them. The facility took approximately two and a half hours to provide all of the client records requested. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Completed documents will be filed in the paper charts in a timely manner. At the time of filing documents in the chart, the service log will be completed to avoid delays in presenting charts upon request.
The Program Director will monitor the service log during chart reviews to ensure that services are documented and the notes are present.
A new Electronic Medical Record will go live on August 9, 2022. This new system will allow for the provision of records in a timely manner.
The Program Director will be able to provide the individual measuring the program's performance a log-in to obtain the records without delay. |