INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 31, 2024 and February 1, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, SpiritLife, Inc was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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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 obtain an informed and voluntary consent from the client which includes specific information disclosed in three of fourteen records.Client #5 was admitted to the detox level of care of December 10, 2023 and was discharged December 18, 2023. Client #5 ' s record contained a release of information dated December 10, 2023 that did not contain specific information to be disclosed. Client #6 was admitted to the detox level of care on October 16, 2023 and was discharged October 18, 2023. Client #6 ' s record contained a release of information dated October 17, 2023 that did not contain specific information to be disclosed. Client #7 was admitted to the detox level of care on November 10, 2023 and was discharged November 15, 2023. Client #7 ' s record contained a release of information dated November 12, 2023 that did not contain specific information to be disclosed. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.28 (c) (2) Confidentiality: Specific information disclosed
1. Immediate Action: Nurse Supervisor & Clinical Supervisor each held mandatory team meetings to review the licensing deficiency with their staff and to educate them on Pa. Code § 255.5 with particular focus on section 709.28 (C) (2) Confidentiality: Specific information disclosed.
2. Plan to achieve and maintain compliance:
a. Initial "Confidentiality" training is to be completed by the HR Manager with all new hires during the orientation phase of employment, to include overview of policies and procedures.
b. On-the-job training in "Chart Documentation" procedures will be the responsibility of the Nursing and Clinical Supervisors, including how to complete valid "Consent to Release" forms disclosing specific information to be disclosed.
c. Chart Audits: Weekly chart audits to be completed by Nursing (DETOX) & Clinical (REHAB) Supervisors. Quality Assurance and Medical Records Clerk to complete records reviews w/in 72-hours of admission to confirm that proper consent is obtained during the admission process.
3. Persons Responsible: Quality Assurance Director, Medical Records Clerk, HR Manager, Nursing Supervisor and Clinical Supervisor
4. Compliance Deadline: Facility to be in full compliance with the licensing standard by 4/1/2024.
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709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to ensure it followed the written procedures for the management of treatment and rehabilitation services for clients in two of five records. Client #11 was admitted to the inpatient level of care on August 4, 2023 and was discharged September 4, 2023. Facility policy and procedure states that a comprehensive treatment plan is to be completed within 72 hours. The first comprehensive treatment plan completed for client #11 was due no later than August 7, 2023. Client #11 ' s first comprehensive treatment plan was completed August 14, 2023.Client #12 was admitted to the inpatient level of care on September 13, 2023 and was discharged October 14, 2023. Facility policy and procedure states that a comprehensive treatment plan is to be completed within 72 hours. The first comprehensive treatment plan completed for client #12 was due no later than September 16, 2023. Client #12 ' s first comprehensive treatment plan was completed September 27, 2023.These findings were reviewed with facility staff during the licensing process. This is a repeat citation from the March 7, 2023 licensing inspection.
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Plan of Correction
709.52 (a) Individual Treatment and Rehab Plan
1. Immediate Action: Clinical Supervisor held a mandatory team meeting to review the licensing deficiency with their staff and to educate them on 709.52 (a) Individual Treatment and Rehab Plan. Also reviewed was the SpiritLife Treatment Planning policy, which states that a Comprehensive Treatment Plan must be completed within 72 hours of admission. Exceptions due to extenuating circumstances or barriers must be documented in the client's chart.
2. Plan to achieve and maintain compliance:
a. On-the-job training in "Chart Documentation" procedures will be the responsibility of the Clinical Supervisor, including the regulatory requirements and company policy on Comprehensive Treatment Plans.
b. Chart Audits: Weekly chart audits to be completed by Clinical Supervisor. Medical Records Clerk to complete records reviews w/in 72-hours of admission to confirm that policy is followed, and the Treatment Plan has been signed by the client and clinical staff.
3. Persons Responsible: Quality Assurance Director, Medical Records Clerk and Clinical Supervisor
Compliance Deadline: Facility to be in full compliance with the licensing standard by 4/1/2024.
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