INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up inspection conducted on January 14, 2022 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, the facility failed to document each counselor met the educational and experiential requirements for the position in one of one staff records.
Staff #3 was hired as a counselor on January 5, 2022. Documentation included a Bachelor degree in a qualifying major; however, Staff #3 did not have the one year of clinical experience upon hire.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the May 6, 7, 20, 2021 licensing inspection.
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Plan of Correction
A comprehensive standard resume/application has been developed that assess candidates clinical experience prior to employment at WR to assure compliance with DDAP counselor guidelines. Additionally a rubric was designed that matches DDAP educational and experiential qualifications. The project director will review each applicant's rubric and application material to ensure compliance with this standard.
Project Director and Facility Director will audit all employee files on a quarterly basis to ensure on-going compliance. |
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 and procedures, 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 plan for agency personnel, an annual evaluation of the overall training plan and failed to clarify the training year time frame.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the May 6, 7, 20, 2021 licensing inspection.
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Plan of Correction
The staff development policies and procedures now include an overall plan for the agency personnel and annual evaluation of the overall training.The 20-21 and 21-22 overall facility training plan including the training year time frame, as well as the 20-21 annual evaluation of the overall training plan, is present in hard copy form at the facility. The Facility Director and Project Director are responsible for completing and evaluating the overall training plan.
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704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of the previous plan of correction and personnel records, the facility failed to document a mechanism to collect feedback on completed training in two of two records reviewed.
Personnel record #1 and #3 included documentation of training certificates. There were no feedback forms documented for the trainings that were completed by staff #1 and #3.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the May 6, 7, 20, 2021 licensing inspection.
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Plan of Correction
Policy states WR assesses training effectiveness through the training feedback form. The Facility director is responsible for the distribution and collection of the feedback form regardless of the route of training whether its via DDAP, vendor, or in house training. The facility director will monitor completion of the feedback form along with training hours. The feedback forms are now placed in the employee training file. Information from the feedback form is summarized in the annual training report and used to inform the following year's training plan. The facility director is responsible for monitoring compliance with this policy. |
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 record.
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. Counselors will provide a hard copy of appropriate training certificate and feedback form. The Facility director will review the training files quarterly to verify training hours complete. Facility Director will keep an on going roster of counselors training hours completed and the amount of hours that need obtained |
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.
Based on the client schedule, the sleeping hours are 11pm - 6:30am Monday - Friday, and 11pm - 7am on Saturday and Sunday. The fire drill logs were reviewed from June 2021 - December 2021. During that timeframe, there were no fire drills conducted during sleeping hours.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the May 6, 7, 20, 2021 licensing inspection.
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Plan of Correction
The fire drills will be conducted and documented by the Project Director. WR fire drill log has been revised to include the hours of 11pm-6:30am Monday through Friday and 11pm-7am on Saturday and Sunday. WR fire drills will be conducted during sleeping hours once at least every 6 months. In this case the policy was not followed and the sleeping hour drill occurred at 9 PM. The facility director through the safety committee will monitor the fire drill log to verify completion of the log and overall compliance. This information will be included in the annual safety committee report. |
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, the facility failed to document a complete written procedure for the management of treatment/rehabilitation services for clients.
The procedure addressing the completion of a psychosocial evaluation was missing who completes the evaluation, the time frame for completion, and how the psychosocial evaluation will be documented.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the May 6, 7, 20, 2021 licensing inspection.
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Plan of Correction
WRs policy and procedures manual has ben revised and the policy of the completion of the Bio-Psycho-Social evaluation is now present in the policies and procedures manual. Project director will monitor compliance of the revised policy and review the policy and procedures manual quarterly. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a review of administrative information, the facility failed to document an annual financial audit associated with the project's drug and alcohol abuse services.
There was no documentation of an annual financial audit for the fiscal years of 2019-2020 and 2020-2021.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the May 15, 2020, and the May 6, 7, 20, 2021 licensing inspection.
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Plan of Correction
In accordance of 709.25 a financial audit is in process with a certified CPA auditor. Results of the audit will be placed on file for review. The project director is responsible for assuring completing of an annual financial audit. By policy audits will occur annually at the completion of the tax year (January 1-Dec 31) and report is due by March 1. The 2019-2020 and 2020-2021 audits are in progress and will completed and available for review on April 15, 2022. |
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 and voluntary consent from the client for the disclosure of information in one of seven client records.
Client #3 was admitted on January 5, 2022 and is currently an active client. Information was disclosed to a laboratory in January 2022 and there was no documentation of a signed consent to release information. The QSOA between the laboratory and the facility expired on December 31, 2021.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the January 11, 2021, and the May 6, 7, 20, 2021 licensing inspection.
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Plan of Correction
QSOA was updated and sent to the operations director of the corresponding laboratory. The QSOA between the laboratory and the facility is now in compliance and the end date now reads upon termination of service. All staff have now been retrained on the correct procedure for disclosure of information. By policy, no information will be released to any facility, person or entity without a signed release of information being present in the treatment record. The CQI committee, with the facility director as chair, will review all client charts weekly to ensure compliance with the ROI policy. The project director is responsible for monitoring all QSOA and verifying end dates. |
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 release information form in three of seven client records.
Client #3 was admitted on January 5, 2022 and is currently an active client. A release of information to a Center of Excellence was signed by the client on January 9, 2022, but did not include the name of the person, agency, or organization.
Client #5 was admitted on October 6, 2021 and was discharged on October 10, 2021. A release of information was signed by the client on October 6, 2021, but did not include the name of the person, agency, or organization.
Client #6 was admitted on November 15, 2021 and was discharged on November 17, 2021. A release of information was signed by the client on November 15, 2021, but did not include the name of the person, agency, or organization.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the January 11, 2021, and the May 6, 7, 20, 2021 licensing inspection.
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Plan of Correction
WR by policy requires the name, agency, or organization appears on on all ROIs. A mandatory staff training has been conducted to improve the compliance of fully completing the ROI in its entirety. Staff members failing to correctly complete the ROI will be tracked and subject to HR disciplinary action as outlined in the employee manual. Records of all admitted patients will be reviewed by the CQI committee weekly to monitor record compliance and accuracy compliance. The facility director is responsible for monitoring compliance of this corrective action plan. |
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 release information form in five of seven client records. Client records # 3, 4, 5, and 6, included releases of information that did not indicate the specific information disclosed, and client record #7 exceeded 255.5 in information to a government agency.
Client #3 was admitted on January 5, 2022 and is currently an active client. A release of information to another agency was signed by the client on January 9, 2022, but did not include the specific information to be disclosed. A release of information to a government agency was signed by the client on January 12, 2022, but did not include the specific information to be disclosed.
Client #4 was admitted on October 26, 2021 and was discharged on October 27, 2021. A release of information to the funding source was signed by the client on October 26, 2021, but did not include the specific information to be disclosed.
Client #5 was admitted on October 6, 2021 and was discharged on October 10, 2021. A release of information was signed by the client on October 6, 2021, but did not include the specific information to be disclosed.
Client #6 was admitted on November 15, 2021 and was discharged on November 17, 2021. A release of information was signed by the client on November 15, 2021, but did not include the specific information to be disclosed.
Client #7 was admitted on December 19, 2021 and is currently an active client. Client record #7 included a release of information to a government agency signed on January 5, 2022 that exceeds 255.5 and allows for the disclosure of treatment plan, medication records, and aftercare plan.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the January 11, 2021, and the May 6, 7, 20, 2021 licensing inspection.
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Plan of Correction
WR by policy requires including specific information to be disclosed on all ROIs. A mandatory staff training has been conducted to improve the compliance of correctly completing the ROI in its entirety. The CQI committee will review all client charts weekly during the CQI meeting. The facility director, as chair of the CQI committee, is responsible for monitoring compliance of this corrective action plan. |
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 release information form in five of seven client records.
Client #3 was admitted on January 5, 2022 and is currently an active client. A release of information to a government agency was signed by the client on January 12, 2022, but did not include the purpose of disclosure.
Client #4 was admitted on October 26, 2021 and was discharged on October 27, 2021. A release of information to the funding source was signed by the client on October 26, 2021, but did not include the purpose of disclosure.
Client #5 was admitted on October 6, 2021 and was discharged on October 10, 2021. A release of information was signed by the client on October 6, 2021, but did not include the purpose of disclosure.
Client #6 was admitted on November 15, 2021 and was discharged on November 17, 2021. A release of information was signed by the client on November 15, 2021, but did not include the purpose of disclosure.
Client #7 was admitted on December 19, 2021 and is currently an active client. Client record #7 included a release of information to a government agency signed on January 5, 2022 that did not indicate a relevant purpose for disclosure of information.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the January 11, 2021, and the May 6, 7, 20, 2021 licensing inspection.
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Plan of Correction
WR by policy requires the purpose of disclosure appears on on all ROIs. A mandatory staff training has been conducted to improve the compliance of fully completing the ROI in its entirety including purpose of disclosure. The CQI committee will review all charts during the CQI meeting to verify that the ROI was completed correctly. The facility director, as chair of the CQI committee, is responsible for compliance monitoring of this CAP. |
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 on the signed consent to release information form in one of seven client records.
Client #3 was admitted on January 5, 2022 and is currently an active client. A release of information for a government agency was signed by the client on January 12, 2022; 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, and the May 6, 7, 20, 2021 licensing inspection.
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Plan of Correction
WR by policy requires the witness date appears on on all ROIs. A mandatory staff training was conducted to improve the compliance of fully completing the ROI in its entirety including a dated signature. The CQI committee will review all charts during the CQI meeting to verify that the ROI was completed correctly. The facility director, as chair of the CQI committee, is responsible for compliance monitoring of this CAP. |
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 the client was offered a copy of the consent in seven of seven client records.
Releases of information found in client records #1, 2, 3, 4, 5, 6 and 7, did not indicate 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, and the May 6, 7, 20, 2021 licensing inspection.
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Plan of Correction
WR by policy requires the documentation the client is offered a copy of the consent the appears on on all ROIs. A mandatory staff training was conducted to improve the compliance of fully completing the ROI in its entirety and offering a copy to the client.The CQI committee will review all charts during the CQI meeting to verify that the ROI was completed correctly. The facility director, as chair of the CQI committee, is responsible for compliance monitoring of this CAP. |
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, the facility failed to indicate the " project, facility or clinical director " may temporarily remove portions of the records. Additionally, the review of the client records, failed to document a written acknowledgement which included all the required client rights in seven of seven client records. The written acknowledgement document provided to clients #1, 2, 3, 4, 5, 6, and 7 did not include the following client 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.
(2)Non-discrimination based on ethnicity, marital status and handicap
(3)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.
(6) 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.
This is a repeat citation from the May 6, 7, 20, 2021 licensing inspection.
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Plan of Correction
WR provides a hard copy of the revised client rights document that contains all required elements to all patients at admission. The written acknowledgement documentation now reads (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.
(2)Non-discrimination based on ethnicity, marital status and handicap
(3)The project director may temporarily remove portions of the record prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. (4)clients are informed that they have the right to submit rebuttal data or memoranda to the project director. This information is reviewed with the medical director.
Staff are instructed to review the client rights with each patient upon admission before the patient signs the documentation. The CQI committee, with facility director as chair, will review all records on a weekly basis to monitor compliance and the presence of a written acknowledge in the record. The project director is responsible for implementing this procedure and overall monitoring for compliance. Additionally, the client rights policy is posted in all common areas of the facility for continuous client review.
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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, the facility failed to indicate, in the policy, the " project, facility or clinical director " may temporarily remove portions of the records. Additionally, based on a review of the client records, the facility failed to document a written client acknowledgement, which is to include all the required client rights in seven of seven client records.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the May 6, 7, 20, 2021 licensing inspection.
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Plan of Correction
WR provides a hard copy of the revised client rights document that contains all required elements to all patients at admission. The written acknowledgement documentation now reads "The project or facility director may temporarily remove portions of the records. A copy of the document will be provided to the client with written acknowledgement placed into the record. The CQI committee, with the facility as chair, will review all charts during the weekly QI meeting to ensure the correct form, written acknowledge and overall compliance with this policy is correct. The project director is responsible for compliance implementation, monitoring and assessment of the civil and client rights polices and procedures. |
709.34 (c) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(5) Outbreak of a contagious disease requiring CDC notification.
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Observations
Based on a review of client records and an interview with facility staff, the facility failed to file a written unusual incident report with the Department within 3 business days following an outbreak of a contagious disease requiring CDC notification.
Client #2 was admitted on December 17, 2021 and was discharged on January 14, 2022. A positive test was documented on December 31, 2021 and was not reported to DDAP.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
WR by the revised policy will report unusual incidents within 3 business days following an outbreak of a contagious disease requiring CDC notification. Additionally, WR on-duty nursing staff will notify the facility, project and medical director immediately when a patient tests positive for a contagious disease. The facility director has now completed the unusual incident report of a contagious disease positive test on 12/31/21 to DDAP. The facility director is responsible for making the DDAP unusual incident report and the Project Director is responsible for monitoring compliance of this corrective action plan. |
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 counseling services were provided according to the treatment and rehabilitation plan in three of four residential client records.
Client #2 was admitted on December 17, 2021 and was discharged on January 14, 2022. The first page of the treatment plan states that individual and group therapy would be provided daily, and subsequent pages state, " individuals at least once weekly " .
There were no group therapy notes documented for December 18, 19, 20, 23, 24, 25, 26, 28, 31, January 1, 2, 5, 6, 10, 11, 12, and 13.
Client #3 was admitted on January 5, 2022 and is currently an active client. The first page of the treatment plan states that individual and group therapy would be provided daily. No group notes were documented for January 11, 13, 2022.
Client #7 was admitted to detox on December 19, 2021, transferred to residential treatment on January 4, 2022 and is currently an active client.
The first page of the treatment plan states that individual and group therapy would be provided daily, and subsequent pages state, " individuals at least once weekly " . No group notes were documented for January 5, 6, 10, 11, and 13, 2022.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the May 6, 7, 20, 2021 licensing inspection.
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Plan of Correction
Per WR policy, treatment standards are daily group therapy participation and at least one weekly individual session. Counselors will ensure that all group and individual therapy session progress notes will be filed within 24 hours of the service provided in accordance to the documented counseling service on the service report. Facility Director will be responsible for monitoring the compliance and accuracy of the treatment plans. Active client charts are reviewed weekly by CQI committee members and upon discharge, are reviewed by the Project and/or Facility Director. |
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 four of four residential client records.
Client #1 was admitted on January 11, 2022 and is currently an active client. The record of services for client #1 did not document services for January 12, 2022. A progress note was documented for January 12, 2022 but was not included on the record of service.
Client #2 was admitted on December 17, 2021 and was discharged on January 14, 2022. There was no record of services documented in client record #2.
Client #3 was admitted on January 5, 2022 and is currently an active client. The record of service form for client # 3 was blank.
Client #7 was admitted to detox on December 19, 2021, transferred to residential treatment on January 4, 2022 and is currently an active client. The record of services for client #7 did not document group sessions.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the January 11, 2021, and the May 6, 7, 20, 2021 licensing inspection.
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Plan of Correction
A Service Record Form is the first document present in all patient charts. The CQI committee audit the active patient charts weekly to monitor compliance. Counselors and/or medical staff must ensure documentation on the Service Record Form align with the progress notes they provided in the chart. The Project Director is responsible for verifying the completion of the Service Record Form. |