INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 6, 7, 20, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Wellness Recovery, 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records and the Staffing Requirements Facility Summary Report, the facility failed to document that each counselor met the educational and experiential requirements for the position in four of four staff records.
Staff #4 was hired as a counselor on August 28, 2020. Staff #4 had documentation of a Bachelor's Degree in Biology, which is not an approved degree, and 4 months of clinical experience.
Staff #5 was hired as a counselor on August 31, 2020. Staff #5 holds a Master's Degree in Christian Leadership, which is not an approved degree. There was no documentation of staff #5's Bachelor's Degree.
Staff #6 was hired as a counselor on May 11, 2020. Staff #6 holds a Bachelor's degree in a qualifying major; however, staff #6 had no clinical experience upon hire.
Staff #7 was hired as a counselor on February 17, 2021. Staff #7 did not have any degree or transcripts present in the personnel record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Personal files have been moved from the business to the facility to improve the efficiency and accuracy of future audits.
2. All personal files were reviewed and both graduate and undergraduate degree transcripts are now included in the files of professional staff.
3. A standard resume/application has been developed that assesses candidates clinical experience prior to employment at WR to assure compliance with DDAP counselor guidelines.
4. The Project Director is responsible for maintenance of HR files and compliance of position qualifications.
5. The project director will audit all employee files on a quarterly basis that |
704.11(a) LICENSURE Staff Development Procedure
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:
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Observations
Based on a review of policies & procedures and facility documentation, the facility failed to document a comprehensive staff development program which included all the required components.
The staff development policies and procedures did not include an overall training plan, an annual evaluation of the overall plan and there were inconsistent dates documented for the training year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. An overall training plan, an evaluation of the plan are required by P and P. The Facility and Project Directors are responsible for completing the plan and the overall evaluation. The 2020-21 plan is now present at the facility.
2. All dates of annual evaluations and reports have been changed for consistency and to reflect a fiscal year format. The reporting time of July 1, to June 30th, with reports due to ownership team by August 1, is now implemented. |
704.11(a)(1) LICENSURE Training Needs assessments
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:
(1) An assessment of staff training needs.
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Observations
Based on a review of the policy & procedures and staff training records, the facility failed to document an assessment of staff training needs.
Individual training plans were not documented in any of the staff records reviewed. In addition, there was no overall facility assessment for staff training needs for the 2020-2021 training year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Individual training plans (ITP), and overall assessment of staff training needs are required by P and P. The Facility and Project Directors are responsible for completing the ITP and reviewing them on an annual basis based upon employee start day.
1. The 2020-21 needs assessment is now present at the facility.
2. The date of the needs assessment report has been changed for consistency and to reflect a fiscal year format. The reporting time of July 1, to June 30th, with reports due to ownership team by August 1, is now implemented.
3. ITP will be reviewed by the Project Director quarterly to monitor for compliance.
4. ITP have been moved from the business office to the facility to facilitate efficiency during inspections. |
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 policy & procedure and staff records, the facility failed to document a mechanism to collect feedback on completed training.
Staff record #1 included documentation of training certificates for the 2020 / 2021 training year. There were no feedback forms documented for the trainings that were completed by staff #1.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
WR, by policy assesses training effectiveness through the Training Feedback form. In this case policy was not followed. The Facility Director is responsible for the distribution, collection and analysis of the training feedback form. All training files will be reviewed by the project director on a quarterly basis to monitor for compliance of feedback on completed training. |
704.11(a)(4) LICENSURE Evaluation of Overall Plan
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:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a review of the policies & procedures, the facility failed to document an annual evaluation of the overall training plan for the 2019 - 2020 training year, which runs April - April.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By policy, the project director completes an annual evaluation of the overall training plan. The plan is presented to the medical director and ownership team. WR has changed the dates of the plan coverage period to reflect a fiscal year format (July 1 to June 30) and to be consistent with other annual reports. The report is due by August 1. The 2019-20 report is now present for review in the facility. |
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 a written individual training plan in seven of seven personnel records.
The facility training year currently runs April - April. The training plans for 2021/2022 were requested. Staff records #1, 2, 3, 4, 5, 6 and 7 did not include the documentation of a training plan.
Staff #1 was hired on Janaury 1, 2019. There was a training plan document in staff record #1; however, it was blank except for the date.
Staff #2 was hired on May 1, 2019. There was no training plan documented in staff record #2.
Staff #3 was hired on October 30, 2019. There was no training plan documented in staff record #3.
Staff #4 was hired on August 8, 2020. There was a training plan document in staff record #4; however, it was blank except for the date.
Staff #5 was hired on August 31, 2020. There was a training plan document in staff record #5; however, it was blank except for the date.
Staff #6 was hired on May 11, 2020. There was a training plan document in staff record #6; however, it was blank except for the date.
Staff #7 was hired on February 17, 2021 There was a training plan document in staff record #7; however, it was blank except for the date.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By policy individual training plans(ITP)are required and placed in the training file for each employee. These records have been moved from the business office to the facility for increased efficiency during audits and inspections. Each employee file now has an individual training plan. The facility and program directors are responsible for maintaining the ITP and auditing each plan quarterly to monitor for progress and compliance. The training plans outline required trainings (Both DDAP and facility)for each employee with documentation of completion dates. |
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 staff training records, the facility failed to document at least 25 hours of training for each counselor in one of one staff records.
Staff #3 was hired as a counselor on October 19, 2019. The training year runs from April - April and the 2020/2021 training year was reviewed. For the training year reviewed, staff #3 did not have any documentation of training.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
WR requires 25 hours of training annually for all counselors. Hard copy proof of training, along with individual training plan are now kept in the employee training file. The facility and Project director are required to review training files quarterly to verify training hour progress towards fulfillment of the policy. Training files have now been moved to the facility to improve accuracy and efficiency of compliance audits and inspections.
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705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of staff records, the facility failed to document fire extinguisher training upon staff employment in four of four staff records.
Staff records #4, 5, 6 and 7 did not include documentation of fire extinguisher training upon staff employment.
Staff #4 was hired on August 28, 2020. There was no documentation of fire extinguisher training in staff record #4.
Staff #5 was hired on August 31, 2020. There was no documentation of fire extinguisher training in staff record #5.
Staff #6 was hired on May 11, 2020. There was no documentation of fire extinguisher training in staff record #6.
Staff #7 was hired on February 17, 2021. There was no documentation of fire extinguisher training in staff record #7.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
WR conducts Fire and Emergency procedure training at hire and annually. Hard copy proof of training is now kept in the employee training file which has been moved to the facility from the business office. All employee files have now have hard copy proof of fire safety training completion. The project director is responsible for fire safety training compliance. The facility and project director is responsible for auditing all employee training files quarterly for compliance of training requirements.
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705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of staff records, the facility failed to ensure staff were trained to perform assigned tasks in an emergency in four of four staff records.
Staff records #4, 5, 6 and 7 did not indicate emergency training was completed upon staff employment.
Staff #4 was hired on August 28, 2020.
Staff #5 was hired on August 31, 2020.
Staff #6 was hired on May 11, 2020.
Staff #7 was hired on February 17, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By policy, WR trains all staff in emergency procedure duties. This occurs during new employee orientation and annually. Conduction of training is the responsibility of the Program Director. Hard copy verification of this training for all staff has been placed in their training file. The program director and facility director audit training records on a quarterly basis to ensure on-going compliance. |
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 a review of fire drill logs, the facility failed to conduct a fire drill during sleeping hours at least every 6 months.
The fire drill logs were reviewed for the time period of May 2020 - May 2021. During that timeframe, there were no fire drills conducted during sleeping hours.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The fire drill log now contains a sleeping hour drill to assess evacuation and staff performance during sleeping hour operations. This drill must occur at least once every six months. The Project Director is responsible for conducting and documenting all fire drills. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of the policy and procedure manual and interviews with facility staff, the facility failed to document complete written procedures for the management of treatment/rehabilitation services for clients.
The entire policy manual was reviewed during this inspection. There were several different locations for policies, they were not all contained at one place. Several of the policies conflicted with one another. In addition, there was no policy addressing the completion of a psychosocial evaluation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The policy and procedure manual has been updated and is contained in once single document. The policy on completion of the Bio-Psycho-Social evaluation is now present in the manual under the Management of treatment/rehabilitation services subsection. The project director is responsible for monitoring compliance of this policy and the ongoing review of the policy and procedure manual. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
The facility failed to document an annual financial audit associated with the project's drug and alcohol abuse services.
An onsite inspection was conducted on May 6-7 & 20, 2021. The annual financial audit was requested. There was no documentation of an annual financial audit for the 2019 - 2020 fiscal year and there was no exception approval.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the May 15, 2020 licensing inspection.
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Plan of Correction
A CPA and certified auditor is under contract to conduct a 2019-20; 2020-21 audit of WR drug and alcohol services. Audits will be conducted annually following a fiscal year format. The audit findings are due to the ownership team on September 30th annually. The Project Director is responsible for the audit progression with the CPA.
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709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records, the facility failed to document written annual performance evaluations in three of three personnel records.
Staff #1 was hired on January 1, 2019. There was no annual performance evaluations documented in staff record #1.
Staff #2 was hired on May 1, 2019. There was no annual performance evaluations documented in staff record #2.
Staff #3 was hired on October 30, 2019. There was no annual performance evaluations documented in staff record #3.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
WR requires annual performance evaluations. The Facility Director is responsible for all performance evaluations of staff. The Project Director is responsible for evaluation of the Facility Director. The Ownership team is responsible for evaluation of the Project Director. Completed annual evaluations are now present in each staff members personal file and the files have been moved from the business office to the facility for increased efficiency during audits and inspections. The Project Director will audit all personal records on a quarterly basis to monitor compliance of this procedure. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of client records, the facility failed to document an informed an voluntary consent from the client for the disclosure of information in two of seven client records.
Client #3 was admitted on March 4, 2021 and discharged on April 1, 2021. There was no signed consent to release information for the funding source in client record #3, even though the facility was receiving funds for this client.
Client #4 was admitted on March 1, 2021 and April 1, 2021. There was no signed consent to release information for the funding source in client record #4 even though the facility was receiving funds for this client. In addition, there was documentation that information was sent to the public defender; however, there was no documentation of a signed consent to release information.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the January 11, 2021 licensing inspection.
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Plan of Correction
WR by policy requires that all incoming patients sign a consent to release information (ROI) to the funding source. A new consent was created that designates 5 point release to funding sources and is now included in the initial intake packet. The facility director is responsible for implementation and monitoring compliance of this policy. Additionally, the CQI committee meets weekly and reviews all charts to review ROI compliance. The old blank release forms have now been removed from the facility. |
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 on the signed consent to treatment in two of seven client records.
Client #4 was admitted on March 1, 2021 and discharged on April 1, 2021. A release of information was singed on March 1, 2021. It was blank and did not include the recipient of the information.
Client #7 was admitted on April 22, 2021 and is currently an active client. A release was documented, no date, that did not include the recipient of the information.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the January 11, 2021 licensing inspection.
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Plan of Correction
WR by policy requires that the name, agency or organization appear on all release of information form. Staff have been trained to fully complete the ROI form in the presence of the patient. The facility director is responsible for implementation and monitoring compliance of this policy. Additionally, the CQI committee meets weekly and reviews all charts to review ROI compliance. |
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 document the specific information disclosed on the signed consent to treatment in five of seven client records.
Client #3 was admitted on March 4, 2021 and discharged on April 1, 2021. Releases were signed on March 4 and March 11, 2021; however, there was no specific information to be released included.
Client #4 was admitted on March 1, 2021 and discharged on April 1, 2021. Releases of information were signed on March 1 and March 8, 2021; however, there was no specific information to be released included.
Client #5 was admitted on April 20, 2021 and is currently an active client. Client #5 signed a consent to release information for the funding source; however, the specific information to be disclosed exceeded what is permitted by Pa Code 255.5.
Client #6 was admitted on May 3, 2021 and is currently an active client. A release of information was signed by the client for the funding source; however, it did not include specific information to be released.
Client #7 was admitted on April 22, 2021 and is currently an active client. A release was documented, no date, that did not include the specific information to be released.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the January 11, 2021 licensing inspection.
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Plan of Correction
WR by policy requires that the specific information to be disclosed appear on the release of information from. Staff have been trained to fully complete the ROI form in the presence of the patient. The facility director is responsible for implementation and monitoring compliance of this policy. Additionally, the CQI committee meets weekly and reviews all charts to review ROI compliance. A new ROI form is now in use that specifically lists the 5 point ROI and prompts staff through accurate completion. |
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 document the purpose of the disclosure on the signed consent to treatment in three of seven client records.
Client #4 was admitted on March 1, 2021 and discharged on April 1, 2021. A release of information was singed on March 1, 2021. It was blank and did not include the purpose of the disclosure.
Client #6 was admitted on May 3, 2021 and is currently an active client. A release was documented for the funding source; however, it did not include the purpose of the disclosure.
Client #7 was admitted on April 22, 2021 and is currently an active client. A release was documented, no date, that did not include the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the January 11, 2021 licensing inspection.
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Plan of Correction
WR by policy requires that the purpose of information disclosure appear on all release of information forms. Staff have been trained to fully complete the ROI form in the presence of the patient. The facility director is responsible for implementation and monitoring compliance of this policy. Additionally, the CQI committee meets weekly and reviews all charts to review ROI compliance. A new ROI form contains prompts to staff to ensure completion of required ROI components. |
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 in one of seven client records.
Client #7 was admitted on April 22, 2021 and is currently an active client. A release was signed by the client; however, the client's signature was not dated.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the January 11, 2021 licensing inspection.
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Plan of Correction
WR by policy requires that the dated signature of the client appear on all release of information forms. Staff have been trained to fully complete the ROI form in the presence of the patient to include signature and date. The facility director is responsible for implementation and monitoring compliance of this policy. Additionally, the CQI committee meets weekly and reviews all charts to review ROI compliance. |
709.28 (c) (5) 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:
(5) Dated signature of witness.
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Observations
Based on a review of client records, the facility failed to document the dated signature of the witness in one of seven client records.
Client #7 was admitted on April 22, 2021 and is currently an active client. A release was signed by the client; however, there was no dated witness signature.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the January 11, 2021 licensing inspection.
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Plan of Correction
WR by policy requires that a dated witness signature appear on all release of information forms. Staff have been trained to fully complete the ROI form in the presence of the patient and to sign and date as a witness. The facility director is responsible for implementation and monitoring compliance of this policy. Additionally, the CQI committee meets weekly and reviews all charts to review ROI compliance. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to document that the client was offered a copy of the consent seven of seven client records.
None of the consents to release information in client records #1, 2, 3, 4, 5, 6 and 7 contained documentation that the client was offered a copy of the consent.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the January 11, 2021 licensing inspection.
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Plan of Correction
WR by policy requires that the patient be offered a copy of the consent to release information form. Staff have been trained to verbally and in writing offer a copy of the ROI and document receipt or denial of the copy. A new ROI form is now in use that prompts staff through offering and documenting the ROI copy to patients. The facility director is responsible for implementation and monitoring compliance of this policy. Additionally, the CQI committee meets weekly and reviews all charts to review ROI compliance. |
709.30 LICENSURE Client Rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
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Observations
Based on a review of the policy and procedure manual and client records, the facility failed to document a written acknowledgement which included all the required client rights.
The written client rights document provided to clients did not include the following client rights:
-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.
-non discrimination based on ethnicity, marital status and handicap
-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. The document states that information can be removed by the counselor.
-Clients have the right to submit rebuttal data or memoranda to their own records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
WR now provides a hard copy of the client rights document that contains all required elements to all patients at admission. The patient signs receipt of the client rights document. Staff have been instructed to review this document with all patients at admission. In addition, WR has posted the client rights document in the common area. Patient files are reviewed weekly by the CQI committee who monitor for compliance. The Project Director is responsible for implementation of the Client Rights procedure. |
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 the policy and procedure manual and client records, the facility failed to document a policy which included:
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.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The statement "clients 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" is now included in our client rights procedure. All clients receive and are provided a hard copy of the civil rights policy. Implementation and compliance monitoring of the Client Rights ppolicy is the responsibility of the Project Director. |
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 the policy and procedure manual and client records, the facility failed to document a policy which included the following client rights:
-non discrimination based on ethnicity, marital status and handicap
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The statement"non discrimination based on ethnicity, marital status and handicap" is now included in the client rights policy. The Project Director is responsible for implementation and compliance monitoring of the policy. |
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 the policy and procedure manual and client records, the facility failed to document a written policy which included:
-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. The policy states that information can be removed by the counselor.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The policy has been changed and now reads "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." The reference to counselor has been removed. The Project Director is responsible for implementation and compliance monitoring of the policy. All clients receive a hard copy of the policy at admission. |
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 the policy and procedure manual and client records, the facility failed to document a policy which included the following client rights:
-Clients have the right to submit rebuttal data or memoranda to their own records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The following statement has been added to the civil rights policy and now reads "Clients have the right to submit rebuttal data or memoranda to their own records." The Project Director is responsible for implementation and compliance monitoring of the policy. All clients receive a hard copy of the policy at admission and are directed to see either the facility or project director for submission of rebuttal information. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on a review of facility documentation, the facility failed to document medication storage area inspections as required by facility policy and regulation.
Facility policy states that inspections of the medication storage areas will take place twice per month and will be signed and dated by two nurses. The inspections for March 2021 only documented one nurse signature and was missing the required information.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the January 11, 2021 licensing inspection.
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Plan of Correction
WR by policy requires inspection of the drug storage area twice per month. Inspection includes 1. outdated drug removal 2. cleanliness 3. Disinfectants and drugs for external use are stored separately from oral and injectable drugs. 4. Proper storage of special condition drugs. 5.Presence of drug-related regulations. Staff nurses have been instructed on the procedure. The Nursing Director is responsible for verification of compliance to the drug inspection procedure. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing of the decision to involuntarily terminate the client's treatment at the project.
Client #3 was admitted on March 4, 2021 and involuntarily terminated on April 1, 2021. There was no documentation of a written notification of termination in client record #3.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
WR policy states that clients must receive written decisions of involuntary termination of care. The written decision must come from either the facility or project director after consultation with the with medical director. Copies of the determination letter must be given to the client and another placed into the client file. The project and medical director are responsible for the review of all involuntary discharges. The project director is responsible for the review and compliance monitoring of this policy. |
709.34 (a) (3) 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:
(3) Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
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Observations
Based on a review of the policy and procedure manual, the facility failed to document a policy which included how it will respond to incidents involving suicide, medication error and unusual circumstances.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
WR has now included a critical incident policy that includes client suicide, medication error and unusual circumstances in the policy and procedure manual. Nursing Director and Project Director are responsible for ongoing review, implementation and compliance of the critical incident policy. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document that counseling services were provided according to the treatment and rehabilitation plan in two of six client records.
Client #2 was admitted February 2, 2021 and discharged on February 20, 2021. The treatment plan dated February 5, 2021 stated that individual and group therapy would be provided daily. There was no therapy notes for February 5, 7, 8, 16 and 19. Individual sessions took place on February 3, 10, 15 and 18.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
WR treatment standards require daily group therapy participation and no less than 1 weekly individual session. The treatment plan was in error when it listed daily individual sessions. All charts will be reviewed weekly by the CQI committee and the facility director to monitor compliance to treatment plans and accuracy of treatment plans. A Service Record Form has been developed as an audit tool that tracks individual and group service delivery. The facility director is responsible for completion of the service record form. |
709.53(a)(3) LICENSURE Records of Service
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(3) Record of services provided.
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Observations
Based on a review of client records, the facility failed to document a record of services provided in three of six client records.
Client #2 was admitted on February 2, 2021 and discharged on February 20, 2021. There was no record of services documented in client record #2.
Client #5 was admitted on April 20, 2021 and is currently an active client. There was no record of services documented in client record #5.
Client #7 was admitted on April 22, 2021 and is currently an active client. There was no record of services documented in client record #7.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the January 11, 2021 licensing inspection.
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Plan of Correction
WR created a Service Record Form that is new present as the first sheet in the chart. The service record form matches services listed in the individual treatment plan. The CQI committee audits all charts on a weekly basis to monitor compliance. The Facility Director audits all charts at discharge to verify completion of the service record form. |