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 September 29, 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, Oil Region Recovery 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 right that 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 did not document that the client was informed of the right that no client may be deprived of a civil right solely by reason of treatment.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
A copy of the client rights was downloaded from the DDAP website and added to the client handbook. Clients will sign document indicating they will not be deprived of civil rights solely on the basis of being in treatment. This will be done on the admission process, and reviewed by the counselor in the initial session with the client. This will be reviewed by the Clinical Director and implemented 10/29/2020 |
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 right that the project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. 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 did not document that the client was informed of the right that the project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Client rights were downloaded from the DDAP website and added to the client chart. Clients will sign a document which becomes part of the client record that indicates the right of the facility Director to remove portions of the client record prior to inspection by the client if the Director determines that the information may be detrimental if presented to the client. The Clinical Director will review client charts to maintain compliance. this will be implemented by 10/29/2020 |
709.34 (c) (4) 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:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
The facility failed to document that a written unusual incident report was submitted to the Department within 3 business days following an unusual incident involving ambulance personnel.
An ambulance was called to the facility on June 25, 2020. There was no documentation that an unusual incident report was submitted to the Department as of the date of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Facility director will review all unusual incident and determine, which incidents are required to be reported to DDAP, and submit within 3 business days. The staff has been retrained to report and submit all unusual incidents directly to the facility director. |
709.52(a)(2) LICENSURE Tx type & frequency
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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
The facility failed to document an individual treatment and rehabilitation plan that included the frequency of treatment and rehabilitation services in three of seven records.
Client records # 1, 2 and 3 did not document the frequency of treatment services the client was to receive.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Counselors were trained on appropriate documentation for the frequency of treatment and rehabilitation services on the client treatment plans. The Clinical Director will review client charts weekly to maintain compliance. This was implemented on 10/29/2020 |
709.54(c) LICENSURE Follow-up policy
709.54. Project management services.
(c) The project shall develop a written client follow-up policy.
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Observations
The facility failed to document follow-up in two of four client records.
Per facility policy, follow-up is to be completed within 7 days of discharge.
Client record # 4 was due to have follow-up completed by March 14, 2020. There was no documentation that follow-up has been completed.
Client record # 7 was due to have follow-up completed by January 19, 2020. There was no documentation that follow-up has been completed
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The counselors will complete the follow up phone call within 7 days of discharge. The counselors will submit the follow up form to the clinical director. The clinical director will verify that all discharged clients will receive a follow up phone call. |