INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 27, 2021 through October 29, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Penn Foundation, 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(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to ensure that the project director completed at least 12 clock hours of annual training during the facility's July 1, 2020 through June 30, 2021 training year in one of one applicable personnel record reviewed. Employee # 1 was hired as the Project Director on September 3, 2010. The personnel record documented 10.25 hours of training. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 11/15/2021, The facility director will complete an audit of completed trainings for the project director two times per year to ensure that the project director completes 12 hours of training per year. Trainings completed outside of the My E-learning platform will be uploaded into the system. |
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 document the completion of 25 clock hours of annual training required for counselors during the facility's July 1, 2020 through June 30, 2021 training year in five of ten applicable personnel records reviewed. Employee # 7 was hired as a counselor on February 20, 2018. The personnel record documented 17 hours of annual training. Employee # 11 was hired as a counselor on March 18, 2019. The personnel record documented 22.5 hours of annual training.Employee # 13 was hired as a counselor on October 14, 2019. The personnel record documented 7 hours of annual training.Employee # 16 was hired as a counselor on June 19, 2017. The personnel record documented 21 hours of annual training.Employee # 17 was hired as a counselor on October 13, 2014. The personnel record documented 19 hours of annual training.These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Effective 11/15/2021 Clinical supervisors and the facility director will complete an audit of the My E-learning training account for each employee three times per year to ensure that employees are working toward or have completed 25 hours of training. Training taken outside of the My E-learning platform will be uploaded in the system. In the event that, an employee does not appear to me making progress toward required training hours the supervisor will discuss during individual supervision. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of the facility-submitted Staffing Requirements Facility Summary Report, the facility failed to ensure that the Full Time Equivalent (FTE) counselor/client ratio did not exceed 35 active clients for two of eight counselors employed. The FTE is determined by dividing the total number of counselor hours devoted to clients by the facility's standard workweek. Then, to obtain the individual ratio, the total number of active clients is divided by the FTE.Employee # 8, the FTE calculation was as follows: 2/40 = .05 (FTE); 2/.05 = 40, which equals to a FTE counselor/client ratio of 40:1.Employee # 10, the FTE calculation was as follows: 8/40 = .2 (FTE); 8/.2 = 40, which equals to a FTE counselor/client ratio of 40:1. This is a repeat citation from the annual renewal inspection conducted on October 1, 2020.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 11/1/2021, clinical supervisors will conduct monthly caseload audits to ensure that counselors consistently meet the counselor/client ratio requirements based on hours worked per week.
Effective 11/15/2021, employee #8 will increase their hours worked per week to 4 which will allow them to maintain their current caseload. Employee #10 will decrease their caseload by 1 client. Employee #10 will have one final session with the client to facilitate warm handoff to the new assigned counselor. This will be completed by 11/30/2021.
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705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on a physical plant inspection conducted on October 28, 2021, the facility failed to store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents. The dumpster, located in the back of the property, had the lids open and was not covered at the time of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 11/15/2021, the maintenance staff will ensure that the dumpster lids are always closed via routine checks of the dumpster area throughout the day. The maintenance supervisor will notify maintenance staff that routine check will be required to comply with this regulation. |
705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection conducted on October 28, 2021, the facility failed to ensure that each bathroom was provided with either individual paper towels or a mechanical dryer in each bathroom. The bathrooms located in rooms # 202, 203, 206, 209, and 215 of the women's residential area did not have individual paper towels or a mechanical dryer in each bathroom. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A waiver will be submitted for this regulation by 11/30/2021. Penn Foundation staff provide a supply of hand towels to clients upon admission as an alternative to mechanical dryer or paper towel dispensers.
If the waiver request is not approved maintenance staff will install paper towel dispensers in each bathroom. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on an administrative review of the facility's October 2020 through September 2021 fire drill logs, the facility failed to conduct a fire drill during sleeping hours at least every 6 months. There were no fire drills conducted during the facility's sleeping hours, which are from 10:30PM to 6AM, during the entire timeframe reviewed.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 11/1/2021, facility maintenance will conduct one fire drill every six months during hours of sleep. The facility director will audit fire drill logs once every six months to ensure compliance. |
709.22 (b) (3) LICENSURE Governing Body
§ 709.22. Governing body.
(b) The duties of the governing body include, but are not limited to, the following:
(3) Documenting the project ' s organizational structure.
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Observations
Based on an administrative review of the facility's policy and procedure manual, the governing body failed to document the project's organizational structure. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The updated organizational chart was placed in the Policy and Procedure manual on 10/29/2021. The facility director will monitor during the annual review of the policy and procedure manual. |
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 review of client records, the facility failed to follow the project's written procedures for the management of treatment/rehabilitation services for clients in the outpatient activity in four of seven client records reviewed. Client # 15 was admitted to the outpatient level of care on June 9, 2021 and was discharged on October 15, 2021. The procedure manual stated that the comprehensive treatment plan would be completed within 60 days of admission. The client's comprehensive treatment plan was due no later than August 9, 2021; however, it was completed on September 24, 2021.Client # 17 was admitted to the outpatient level of care on March 5, 2021 and was discharged on June 21, 2021. The procedure manual stated that the comprehensive treatment plan would be completed within 60 days of admission. The client's comprehensive treatment plan was due no later than May 5, 2021; however, it was completed on May 10, 2021. Client # 18 was admitted to the outpatient level of care on January 6, 2021 and was discharged on September 8, 2021. The procedure manual stated that the comprehensive treatment plan would be completed within 60 days of admission. The client's comprehensive treatment plan was due no later than March 6, 2021; however, it was completed on March 27, 2021. Client # 19 was admitted to the outpatient level of care on February 23, 2021 and was still active at the time of inspection. The procedure manual stated that the comprehensive treatment plan would be completed within 60 days of admission. The client's comprehensive treatment plan was due no later than April 23, 2021; however, it was completed on June 9, 2021. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 11/11/2021, the outpatient clinical supervisor will review, in group supervision, the policy for completing comprehensive treatment plans within 60 days of admission to the program. The clinical supervisor will conduct random treatment plan audits quarterly to ensure compliance. |
709.28 (c) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom a disclosure was to be made to on release of information forms in one of twenty-eight client records reviewed.Client #9 was admitted to the residential level of care on August 25, 2021 and was discharged on October 1, 2021. A release of information form was signed and dated by the client on August 20, 2021, but the form did not indicate the name of the person, agency, or organization the information would be disclosed to. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director completed an audit of Consent to Release Information Forms on 11/5/2021 and saw no evidence of a pattern of missing information on consent forms, therefore the staff person who completed the release of information in this case was retrained in completing release of information forms on 11/8/2021. The program director will conduct quarterly chart audits to ensure release of information form are completed in their entirety. |
709.28 (c) (4) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document the dated signature of the client on release of information forms in eleven of twenty-eight client records reviewed. Client # 11 was admitted to the residential level of care on August 9, 2021 and was discharged on October 25, 2021. There was a release of information form to another treatment facility signed by the witness on September 17, 2021. However, the form did not include the dated signature of the client. Client # 17 was admitted to the outpatient level of care on March 5, 2021 and was discharged on June 21, 2021. There was a release of information form to a funding source signed and dated by the witness on March 5, 2021, and a release of information form to a healthcare provider, signed and dated by the witness on March 19, 2021. However, both release forms did not include the dated signature of the client.Client # 18 was admitted to the outpatient level of care on January 6, 2021 and was discharged on September 8, 2021. There was a release of information form to a funding source signed and dated by the witness on January 6, 2021. However, the form did not include the dated signature of the client.Client # 19 was admitted to the outpatient level of care on February 23, 2021 and was still active at the time of inspection. There was a release of information form to a funding source signed and dated by the witness on February 23, 2021. However, the form did not include the dated signature of the client.Client # 21 was admitted to the outpatient level of care on March 9, 2021 and was still active at the time of inspection. There was a release of information form to a funding source signed and dated by the witness on March 9, 2021. However, the form did not include the dated signature of the client.Client # 22 was admitted for evaluation services only on December 28, 2020 and was discharged on December 30, 2021. There was a release of information form to a funding source signed and dated by the witness on December 28, 2020. However, the form did not include the dated signature of the client.Client # 23 was admitted for evaluation services only on January 13, 2021 and was discharged on January 20, 2021. There was a release of information form to probation and parole signed and dated by the witness on January 15, 2021. However, the form did not include the dated signature of the client.Client # 25 was admitted for evaluation services only on May 6, 2021 and was discharged on May 11, 2021. There was a release of information form to probation and parole and a release of information form to a funding source, both signed and dated by the witness on May 10, 2021; however, neither release form included the dated signature of the client.Client # 26 was admitted for evaluation services only on July 13, 2021 and was discharged on July 28, 2021. There were two release of information forms to a government agency, one signed by the witness on July 13, 2021 and the other signed by the witness on July 19, 2021. However, both release forms did not include the dated signature of the client.Client #27 was admitted for evaluation services only on March 10, 2021 and was discharged on March 23, 2021. There was a release of information form to an attorney signed by the witness on March 16, 2021. However, the form did not include the dated signature of the client.Client #28 was admitted for evaluation services only on February 11, 2021 and was discharged March 18, 2021. There was a release of information form to a government agency and a release of information form to another treatment facility, both signed by the witness on February 11, 2021. However, neither form included the dated signature of the client.This is a repeat citation from the annual renewal inspection conducted on October 1, 2020.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Due to COVID-19 emergency procedures verbal consent to disclose information in the client record was obtained, and the Release of Information form was mailed to persons served to sign and return, per the 2020 plan of correction. Individuals did not consistently return the mailed forms. Effective, 9/1/2021 all persons served are required to come in person for their level of care assessment to ensure that Releases of Information contain a live signature. For persons already enrolled in treatment services the counselor or case manager will arrange for the person to come on site to sign a Release of Information form before their next scheduled appointment. Effective 11/1/2021, clinical supervisors will conduct quarterly chart audits to ensure compliance. |
709.30 (1) 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.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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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 that a client receiving care of treatment under section 7 of the act (71 P. S. 1690.107) shall retain civil rights and liberties except as provided by status and that no client may be deprived of a civil right solely by reason of treatment in eleven of twenty-eight client records reviewed.Client # 10 was admitted to the residential level of care on May 21, 2021 and was discharged on June 14, 2021. Client # 17 was admitted to the outpatient level of care on March 5, 2021 and was discharged on June 21, 2021. Client # 18 was admitted to the outpatient level of care on January 6, 2021 and was discharged on September 8, 2021. Client # 19 was admitted to the outpatient level of care on February 23, 2021 and was still active at the time of inspection. Client # 21 was admitted to the outpatient level of care on March 9, 2021 and was still active at the time of inspection. Client # 22 was admitted for evaluation services only on December 28, 2020 and was discharged on December 30, 2021. Client # 23 was admitted for evaluation services only on January 13, 2021 and was discharged on January 20, 2021. Client # 25 was admitted for evaluation services only on May 5, 2021 and was discharged on May 11, 2021. Client # 26 was admitted for evaluation services only on July 13, 2021 and was discharged on July 18, 2021. Client # 27 was admitted for evaluation services only on March 10, 2021 and was discharged on March 23, 2021. Client # 28 was admitted for evaluation services only on February 11, 2021 and was discharged on March 18, 2021. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Due to COVID-19 emergency procedures and services being delivered virtually, verbal consent was obtained and documents in the client record related to client rights. Effective, 9/1/2021 all persons served are required to come in person for their level of care assessment to ensure that a live signature is obtained on the acknowledgment receipt form stating that they have been informed of their right to retain civil rights and liberties except as provided by statute and that no client may be deprived of a civil right solely by treatment. Effective 11/1/2021 clinical supervisors will conduct quarterly chart audits to ensure compliance. |
709.30 (2) 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.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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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 that the project may not discriminate in the provision of services basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion in eleven of twenty-eight client records reviewed. Client # 10 was admitted to the residential level of care on May 21, 2021 and was discharged on June 14, 2021. Client # 17 was admitted to the outpatient level of care on March 5, 2021 and was discharged on June 21, 2021. Client # 18 was admitted to the outpatient level of care on January 6, 2021 and was discharged on September 8, 2021. Client # 19 was admitted to the outpatient level of care on February 23, 2021 and was still active at the time of inspection. Client # 21 was admitted to the outpatient level of care on March 9, 2021 and was still active at the time of inspection. Client # 22 was admitted for evaluation services only on December 28, 2020 and was discharged on December 30, 2021. Client # 23 was admitted for evaluation services only on January 13, 2021 and was discharged on January 20, 2021. Client # 25 was admitted for evaluation services only on May 5, 2021 and was discharged on May 11, 2021. Client # 26 was admitted for evaluation services only on July 13, 2021 and was discharged on July 18, 2021. Client # 27 was admitted for evaluation services only on March 10, 2021 and was discharged on March 23, 2021. Client # 28 was admitted for evaluation services only on February 11, 2021 and was discharged on March 18, 2021. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Due to COVID-19 emergency procedures and services being delivered virtually, verbal consent was obtained and documents in the client record related to client rights. Effective, 9/1/2021 all persons served are required to come in person for their level of care assessment to ensure that a live signature is obtained on the acknowledgment receipt form stating that they have been informed of their right that the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap, or religion. Effective 11/1/2021 clinical supervisors will conduct quarterly chart audits to ensure compliance. |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they were notified that they have the right to inspect their own record and that the project, facility, or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client in eleven of twenty-eight client records reviewed. Client # 10 was admitted to the residential level of care on May 21, 2021 and was discharged on June 14, 2021. Client # 17 was admitted to the outpatient level of care on March 5, 2021 and was discharged on June 21, 2021. Client # 18 was admitted to the outpatient level of care on January 6, 2021 and was discharged on September 8, 2021. Client # 19 was admitted to the outpatient level of care on February 23, 2021 and was still active at the time of inspection. Client # 21 was admitted to the outpatient level of care on March 9, 2021 and was still active at the time of inspection. Client # 22 was admitted for evaluation services only on December 28, 2020 and was discharged on December 30, 2021. Client # 23 was admitted for evaluation services only on January 13, 2021 and was discharged on January 20, 2021. Client # 25 was admitted for evaluation services only on May 5, 2021 and was discharged on May 11, 2021. Client # 26 was admitted for evaluation services only on July 13, 2021 and was discharged on July 18, 2021. Client # 27 was admitted for evaluation services only on March 10, 2021 and was discharged on March 23, 2021. Client # 28 was admitted for evaluation services only on February 11, 2021 and was discharged on March 18, 2021. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Due to COVID-19 emergency procedures and services being delivered virtually, verbal consent was obtained and documents in the client record related to client rights. Effective, 9/1/2021 all persons served are required to come in person for their level of care assessment to ensure that a live signature is obtained on the acknowledgment receipt form stating that they have been informed of their right to inspect their own records and that the project, facility, or clinical director may temporarily remove portions of the record that are deemed to be detrimental to the client when the client is reviewing the record. Effective 11/1/2021 clinical supervisors will conduct quarterly chart audits to ensure compliance.
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709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right to appeal a decision limiting access to their records to the director in eleven of twenty-eight client records reviewed.Client # 10 was admitted to the residential level of care on May 21, 2021 and was discharged on June 14, 2021. Client # 17 was admitted to the outpatient level of care on March 5, 2021 and was discharged on June 21, 2021. Client # 18 was admitted to the outpatient level of care on January 6, 2021 and was discharged on September 8, 2021. Client # 19 was admitted to the outpatient level of care on February 23, 2021 and was still active at the time of inspection. Client # 21 was admitted to the outpatient level of care on March 9, 2021 and was still active at the time of inspection. Client # 22 was admitted for evaluation services only on December 28, 2020 and was discharged on December 30, 2021. Client # 23 was admitted for evaluation services only on January 13, 2021 and was discharged on January 20, 2021. Client # 25 was admitted for evaluation services only on May 5, 2021 and was discharged on May 11, 2021. Client # 26 was admitted for evaluation services only on July 13, 2021 and was discharged on July 18, 2021. Client # 27 was admitted for evaluation services only on March 10, 2021 and was discharged on March 23, 2021. Client # 28 was admitted for evaluation services only on February 11, 2021 and was discharged on March 18, 2021. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Due to COVID-19 emergency procedures and services being delivered virtually, verbal consent was obtained and documents in the client record related to client rights. Effective, 9/1/2021 all persons served are required to come in person for their level of care assessment to ensure that a live signature is obtained on the acknowledgment receipt form stating that they have been informed of their right to appeal a decision limiting access to their records to the director. Effective 11/1/2021 clinical supervisors will conduct quarterly chart audits to ensure compliance. |
709.30 (5) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they had been informed of their right to request the correction of inaccurate, irrelevant, outdated, or incomplete information in eleven of twenty-eight client records reviewed. Client # 10 was admitted to the residential level of care on May 21, 2021 and was discharged on June 14, 2021. Client # 17 was admitted to the outpatient level of care on March 5, 2021 and was discharged on June 21, 2021. Client # 18 was admitted to the outpatient level of care on January 6, 2021 and was discharged on September 8, 2021. Client # 19 was admitted to the outpatient level of care on February 23, 2021 and was still active at the time of inspection. Client # 21 was admitted to the outpatient level of care on March 9, 2021 and was still active at the time of inspection. Client # 22 was admitted for evaluation services only on December 28, 2020 and was discharged on December 30, 2021. Client # 23 was admitted for evaluation services only on January 13, 2021 and was discharged on January 20, 2021. Client # 25 was admitted for evaluation services only on May 5, 2021 and was discharged on May 11, 2021. Client # 26 was admitted for evaluation services only on July 13, 2021 and was discharged on July 18, 2021. Client # 27 was admitted for evaluation services only on March 10, 2021 and was discharged on March 23, 2021. Client # 28 was admitted for evaluation services only on February 11, 2021 and was discharged on March 18, 2021. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Due to COVID-19 emergency procedures and services being delivered virtually, verbal consent was obtained and documents in the client record related to client rights. Effective, 9/1/2021 all persons served are required to come in person for their level of care assessment to ensure that a live signature is obtained on the acknowledgment receipt form stating that they have been informed of their right to request the correction of inaccurate, irrelevant, outdated, or incomplete information in their records. Effective 11/1/2021 clinical supervisors will conduct quarterly chart audits to ensure compliance. |
709.30 (6) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they had been informed of their right to submit rebuttal data or memoranda to their own records in eleven of twenty-eight client records reviewed.Client # 10 was admitted to the residential level of care on May 21, 2021 and was discharged on June 14, 2021. Client # 17 was admitted to the outpatient level of care on March 5, 2021 and was discharged on June 21, 2021. Client # 18 was admitted to the outpatient level of care on January 6, 2021 and was discharged on September 8, 2021. Client # 19 was admitted to the outpatient level of care on February 23, 2021 and was still active at the time of inspection. Client # 21 was admitted to the outpatient level of care on March 9, 2021 and was still active at the time of inspection. Client # 22 was admitted for evaluation services only on December 28, 2020 and was discharged on December 30, 2021. Client # 23 was admitted for evaluation services only on January 13, 2021 and was discharged on January 20, 2021. Client # 25 was admitted for evaluation services only on May 5, 2021 and was discharged on May 11, 2021. Client # 26 was admitted for evaluation services only on July 13, 2021 and was discharged on July 18, 2021. Client # 27 was admitted for evaluation services only on March 10, 2021 and was discharged on March 23, 2021. Client # 28 was admitted for evaluation services only on February 11, 2021 and was discharged on March 18, 2021. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Due to COVID-19 emergency procedures and services being delivered virtually, verbal consent was obtained and documents in the client record related to client rights. Effective, 9/1/2021 all persons served are required to come in person for their level of care assessment to ensure that a live signature is obtained on the acknowledgment receipt form stating that they have been informed of their right to submit rebuttal data or memoranda to their own records. Effective 11/1/2021 clinical supervisors will conduct quarterly chart audits to ensure compliance. |
709.34 (a) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(5) Theft, burglary, break-in or similar incident at the facility.
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Observations
Based on an administrative review of the facility's policy and procedure manual, the facility failed to develop and implement policies and procedures to respond to the unusual incident of a theft, burglary, break-in or similar incident at the facility. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Risk management/Unusual Incident Policy was updated on 10/29/2021 to include incident of a theft, burglary, break-in, or similar incident. The policy and procedure manual was updated at this time. The facility director will review the policy and procedure manual annually. |
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 on an individual, which is to include follow-up information, in two of four applicable client records reviewed.Client # 15 was admitted to the outpatient level of care on June 9, 2021 and was discharged on October 15, 2021. The written procedure manual stated that follow-up will be completed within 7 days of discharge. There was no follow-up information documented in the client record at the time of inspection. Client # 18 was admitted to the outpatient level of care on January 6, 2021 and was discharged on September 8, 2021. The written procedure manual stated that follow-up will be completed within 7 days of discharge. There was no follow-up information documented in the client record at the time of inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 11/15/2021, support staff will conduct a follow up call within 7 days of the client's discharge from Penn Foundation Outpatient Services to determine the status of the client. Support staff will document the follow up call on the blank note form. The clinical supervisor will conduct quarterly chart audits to ensure compliance. |