INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection. The inspection will be divided into two parts. 1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist. 2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.This report is a result of Part 2, an abbreviated on-site inspection, conducted on October 8, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.Based on the findings of Part 2, an abbreviated on-site inspection, New Freedom Recovery Center, LLC was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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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
The facility failed to document that clients were informed of the rights that they 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 in seven of seven records. Client records # 1, 2, 3, 4, 5, 6 and 7 documented that the client has received the client handbook which contained the client rights. The clients right that they shall retain civil rights and liberties except as provided by statute and that no client may be deprived of a civil right solely by reason of treatment was not documented in the handbook. There was no further documentation provided that the clients were informed of this right. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon instructions from the Project Director, the Human Resource Manager has updated all Client Handbooks and will insure that future Client Handbooks, contain the correct Client Rights to be in compliance with 709.30 (1). |
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
The facility failed to document that clients were informed of the rights that the facility may not discriminate in the provision of services based on creed, ethnicity, color, marital status and sexual orientation in seven of seven records. Client records # 1, 2, 3, 4, 5, 6 and 7 documented that the client has received the client handbook which contained the client rights. The handbook did not document that the facility may not discriminate in the provision of services based on creed, ethnicity, color, marital status and sexual orientation There was no further documentation provided that the clients were informed of this right. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon instructions from the Project Director, the Human Resource Manager has updated all Client Handbooks and will insure that future Client Handbooks, contain the correct Client Rights to be in compliance with 709.30 (2). |
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
The facility failed to document that clients were informed of the rights that they 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 in seven of seven records. Client records # 1, 2, 3, 4, 5, 6 and 7 documented that the client has received the client handbook which contained the client rights. The handbook did not document that they 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. There was no further documentation provided that the clients were informed of this right. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon instructions from the Project Director, the Human Resource Manager has updated all Client Handbooks and will insure that future Client Handbooks, contain the correct Client Rights to be in compliance with 709.30 (3). |
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
The facility failed to document that clients were informed of the rights that they could appeal a decision limiting access to their records to the director in seven of seven records. Client records # 1, 2, 3, 4, 5, 6 and 7 documented that the client has received the client handbook which contained the client rights. The handbook did not document that they could appeal a decision limiting access to their records to the director. There was no further documentation provided that the clients were informed of this right. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon instructions from the Project Director, the Human Resource Manager has updated all Client Handbooks and will insure that future Client Handbooks, contain the correct Client Rights to be in compliance with 709.30 (4). |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
The facility failed to document case consultations notes in four of five client records. Per Agency policy, case consults were to be completed monthly. Client # 4 did not document case consultation notes for the months of November and December 2019. Client # 5 did not document case consultation notes for the month of December 2019. Client # 6 did not document case consultation notes for the month of April 2020.Client # 7 did not document case consultation notes for the month of August 2020.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director and Clinical Supervisor reviewed with all therapists that Case Consults must be documented monthly for all clients in treatment. The Project Director will ensure that we are in compliance with Pa Code 709.93 (a) (8). |
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
The facility failed to document follow-up information in three of four client records.Per Agency policy, follow-up is to be completed within 7 days of discharge. Client # 4 was to have a follow-up completed by January 9, 2020. There was no follow-up documented.Client # 6 was to have a follow-up completed by May 14, 2020. There was no follow-up documented.Client # 7 was to have a follow-up completed by October 1, 2020. There was no follow-up documented.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director met with the Clinical Supervisor and all therapists to review follow-up calls and notes on all clients that have been discharged from treatment. The Project Director has reminded all clinical staff that a follow up call must be completed within 7 days of discharge and follow notes must be documented in the client record. The Project Director will review client records to insure that follow up calls and notes have been completed in compliance with 709.93(a)(11). |