INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up inspection conducted on April 19 - 21, 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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704.2(b) LICENSURE Staffing Plan
704.2. Compliance plan.
(b) The plan documenting the qualifications and training of staff shall be presented to Department licensing representatives at the time of the project's site visit.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR), the facility failed to provide a complete form. The SRFSR was requested to be completed on the first day of the inspection, April 19, 2022. The SRFSR was still not complete by the last day of the inspection on April 21, 2022. The form presented did not include support staff and nursing staff, and other sections of the form were incomplete.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The SRFSR has now been updated and includes all nursing and support staff. The form is now present as a database template for faster completion during the next licensing review. The project director is responsible for maintaining an up to date SRFSR. |
704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on a review of the personnel record, the facility failed to document the facility director met the qualifications for the position.
Staff # 2 was promoted to the facility director position on March 10, 2022. Based on the documentation provided, Staff #2 meets the educational requirements for the position, and has at least two years of experience in direct service, but did not have experience documented for the supervision of others and program planning.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An updated CV that clearly outlines the facility director's supervision and program planning history is now present in the personal file. Additionally, a position qualification and compliance section has been added to the initial HR application and is now present in each employee chart. This section is used for the positions of medical director, counselor, counselor assistant, facility director and project director as a way to monitor validation of degree, education and training history, clinical experience, supervision of others and program planning and development as it applies to the regulation for each position. The project director is responsible for completing this form prior to first day of hire. |
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 three staff records.
Staff #4 began as a counseling intern on January 10, 2022. Documentation included a Bachelor's Degree in a qualifying major; however, Staff #4 did not have the one year of clinical experience upon hire. Group progress notes indicated she is the sole facilitator.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the May 2021, and January 2022 licensing inspections.
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Plan of Correction
An updated CV that clearly outlines the counselors clinical experience is now present in the personal file.Additionally, a position qualification and compliance section has been added to the initial HR application and is now present in each employee chart. This section is used for the positions of medical director, counselor, counselor assistant, facility director and project director as a way to monitor validation of degree, education and training history, clinical experience, supervision of others and program planning and development as it applies to the regulation for each position. The project director is responsible for completing this form prior to first day of hire. |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, the facility failed to prohibit the use of heaters that are not permanently mounted or installed.
On April 19, 2022 at approximately 11:40 AM, a portable heater was observed in the downstairs facility director office.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The employee failed to follow the safety policy which prohibits portable heaters. A warning memo was sent to the employee to remove the heater from their office. The project director also sent a facility wide email reminding all staff of the procedure. The project director will perform a weekly inspection of the facility to monitor for compliance. The project director is responsible for monitoring the fire safety policy. |
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on a review of administrative information, the facility failed to provide a written policy and procedure manual during the April 19-21, 2022 inspection. Various policies and procedures were provided but not a written manual delineating project policies and procedures.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An updated policy and procedure manual is now present at the facility in both hard copy and electronic format. The manual reflects and updated date of May 15, 2022. The project director is responsible for maintaining and updating the manual as needed. |
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 policy and procedure for notifying emergency contacts of when an individual leaves treatment against medical advice to comply with Act 41 of 2021. The policy and procedure presented was missing the time frame for completion, and how it will be documented. A form was developed to document the notification, but two of two client records reviewed did not include the documentation.
Client #7 was admitted on April 12, 2022 and was discharged against medical advice on April 18, 2022.
Client #8 was admitted on April 13, 2022 and discharged against medical advise on April 17, 2022.
These findings were reviewed with facility staff during the licensing process.
This regulation is a repeat citation from the May 2021 and January 2022 licensing inspections.
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Plan of Correction
The procedure for AMA discharges now lists the time frame (i.e. immediately or within one hour of departure if the nurse is handling an emergency) for notification to emergency contacts. This procedure is now present in the P and P manual on-site. Documentation is made on the the AMA form which also notes the emergency contact. By policy, only the duty nurse will meet with the AMA seeking client, provide narcan along with education on the dangers of leaving treatment. The medical, facility and project directors will also be immediately notified by the duty nurse when a client leaves AMA. All staff members have been trained in the use of the form and the procedure. |
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 2020, May 2021, and January 2022 licensing inspections.
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Plan of Correction
A state certified auditor has been paid and is under contract for the production of fiscal audits for fys 19-20, 20-21 and 21-22. The auditors are currently in the process of review. The results of the audit will be made available on-site as soon as they are submitted by the auditors. The project director is responsible for ensuring the prior year audits are completed as well as contracting annually with a state certified auditor as required by DDAP regulations. |
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 one of six client records.
Client #1 was admitted on March 21, 2022 and was still an active client. A release of information to a Center of Excellence was signed by the client on March 23, 2022, 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 2021, May 2021, and January 2022 licensing inspections.
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Plan of Correction
New consent forms have been developed, including the effective dates, directions of revocation, intended purpose and specific information released. Following the release of new documentation, staff members have been alerted and trained on its completion and purpose. In particular, training addressed correct documentation of agencies, persons, or organizations. The facility director is responsible for auditing all charts weekly to verify 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 release information form in six of six client records. Client records # 1, and 5, included releases of information that did not indicate the specific information disclosed, and client record #2, 3, 4, 5, 6 exceeded 255.5 in information to a government agency.
Client #1 was admitted on March 21, 2022 and was still an active client. A release of information to a funder signed on March 21, 2022 did not indicate the specific information to be disclosed. A release of information to another agency was signed on April 13, 2022 did not indicate the specific information to be disclosed.
Client #2 was admitted on March 21, 2022 and is currently an active client. A release of information to a funder signed on March 21, 2022, exceeded 255.5 allowing for the release of treatment plan, discharge summary / aftercare plan.
Client #3 was admitted on April 3, 2022 and is currently an active client. A release of information to a funder signed on April 2, 2022 exceeded 255.5 allowing for the release of treatment plan, discharge summary / aftercare plan.
Client #4 was admitted on April 6, 2022 and is a current client. A release of information to a funder signed on April 6, 2022 exceeded 255.5 allowing for the release of treatment plan, discharge summary / aftercare plan.
Client #5 was admitted on February 16, 2022 and was discharged March 15, 2022. A release of information to a funder signed on February 16, 2022 exceeded 255.5 allowing for the release of treatment plan, discharge summary / aftercare plan. Two separate releases for an emergency contact signed on February 16, 2022 did not indicate the specific information to be disclosed.
Client #6 was admitted on February 17, 2022 and was discharged on April 5, 2022. A release of information to a funder signed on February 17, 2022 exceeded 255.5 allowing for the release of treatment plan, discharge summary / aftercare plan.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the January 2021, May 2021, and January 2022 licensing inspections.
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Plan of Correction
New consent forms have been developed, including effective dates, directions for revocation, intended purpose, and specific information released. Following the release of new documentation, staff members have been alerted and trained on its completion and purpose. In particular, training addressed client confidentiality and educated staff on specific information allowed to disclose to various parties (ie government officials, health plans, medical providers, etc.) The facility director is responsible for auditing all charts weekly to verify compliance. |
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 three of six client records.
Client #1 was admitted on March 21, 2022 and was still an active client. A release of information to a funder signed on March 21, 2022, the purpose was not indicated.
Client #4 was admitted on April 6, 2022 and is a current client. A release of information to another agency was signed on April 7. 2022, the purpose was not indicated.
Client #5 was admitted on February 16, 2022 and was discharged March 15, 2022. A release of information to a funder signed on February 16, 2022, the purpose was not indicated.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the January 2021, May 2021, January 2022 licensing inspections.
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Plan of Correction
New consent forms have been developed, including the effective dates, directions for revocation, intended purpose and specific information released. Following the release of new documentation, staff members have been alerted and trained on its completion and purpose. In particular, training addressed client confidentiality and educated staff on the importance of documenting and understanding the specific purpose for each release/consent to disclose. The facility director is responsible for auditing all charts weekly to verify compliance. |
709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of client records, the facility failed to document the expiration date, condition or event upon which the consent would expire in one of six client records.
Client #1 was admitted on March 21, 2022 and was still an active client. A release of information to a funder was signed on March 21, 2022, did not indicate the expiration date, condition or event upon which the consent would expire.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
New consent forms have been developed, including the effective dates, directions for revocation, intended purpose, and specific information released. Following the release of new documentation, staff members have been alerted and trained on its completion and purpose. In particular, training addressed client confidentiality-and the dates, events or conditions for which the consent is valid. The facility director is responsible for auditing all charts weekly to verify 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 the client was offered a copy of the consent in one of six client records.
Client #1 was admitted on March 21, 2022 and was still an active client. A release of information to a funder signed on March 21, 2022, 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 2021, May 2021, and January 2022 licensing inspection.
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Plan of Correction
Staff have been trained on correct completion of consent/release of records forms. In particular, documenting whether clients were offered a copy of their consents was addressed explicitly by the facility director. The facility director is responsible for auditing all charts weekly to verify 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 client records, the facility failed to document a written acknowledgement which included all the required client rights in six of six client records.
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 nurse/therapist.
-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 2021 and January 2022 licensing inspections.
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Plan of Correction
The client rights form has been updated to include a written acknowledgement of client rights. The client rights form that is given to clients during intake now parallels DDAP regulations. Language of nurse/therapist removal of records no longer appears on the form. All records will be reviewed weekly during the CQI meeting to insure compliance. All staff who preform initial intake have been trained on the Client Rights procedure. The facility director is responsible for monitoring on-going compliance with this policy. |
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 client records, the facility failed to document that each client was informed of the following client right in six of six client records:
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 client rights form has been updated to include section 7 retention of civil rights and liberties. The civil rights procedure now parallels DDAP regulations. All staff who preform initial intake have been trained on the Client Rights procedure. The facility director is responsible for monitoring on-going compliance with this policy. |
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 client records, the facility failed to document that each client was informed of the following client rights in six of six client records:
-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 client rights form has been updated to include the required non-discrimination language. The civil rights procedure now parallels DDAP regulations. All staff who preform initial intake have been trained on the Client Rights procedure. The facility director is responsible for monitoring on-going compliance with this policy.
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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 client records, the facility failed to document that each client was provided with the following client right in six of six client 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. The written acknowledgement states that information can be removed by the nurse/therapist.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the January 14, 2022 and May 20, 2021 licensing inspections.
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Plan of Correction
The client rights form has been updated to include only the facility, clinical or project director as having the authority to temporarily remove information. The nurse/therapist language has been removed. The civil rights procedure now parallels DDAP regulations. All staff who preform initial intake have been trained on the Client Rights procedure. The facility director is responsible for monitoring on-going compliance with this policy.
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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 client records, the facility failed to document that each client was provided with the following client right in six of six client records:
-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 client rights form has been updated to include a statement about record rebuttal rights. The civil rights procedure now parallels DDAP regulations. All staff who preform initial intake have been trained on the Client Rights procedure. The facility director is responsible for monitoring on-going compliance with this policy.
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709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
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Observations
Based on the review of administrative documentation and client records, the facility failed to efficiently retrieve information needed for the annual onsite licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project director will prepare and ensure the on-going maintenance of a staging area in the front office so that documentation and client records are immediately available upon DDAP request. This area will consist of a system computer with access to policy and procedure manual, training records, licensing documents, financial audits and annual reports. The area will also contain hard copies of employee files, training material and completed client records as requested. On-going WR is in the process of contracting with an EMR system to eliminate the confusion of paper-charts. The system is estimated to be in-place by September 1, 2022. The project director is responsible for contracting with an EMR system. |
709.64(e) LICENSURE Follow-up policy
709.64. Project management services.
(e) The project shall develop a written client follow-up policy.
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Observations
Based on a review of the policy provided, the facility failed to address follow up for all clients who have been discharged from the project. Follow up for non-referred clients is not addressed in the policy.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The policy has been updated and now reads that a 72 hour and 30 day follow-up be performed on all discharged clients. The facility director is responsible for ensuring completion of discharge follow-ups and monitoring on-going compliance of the follow-up policy |
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 March 21, 2022 and was still an active client. Progress notes were documented for individual and group sessions on March 28, 30, 31, April 1, 3, 4, 5, 6, 7, 13, and 14, 2022. There were no corresponding entries on the record of service for these dates.
Client #2 was admitted on March 21, 2022 and is currently an active client. Progress notes were documented group sessions on March 21, 23, 24, 26, 27, 28, 29, 30, 31, April 1, 2, 3, 4, 5, and 6, 2022. There were no corresponding entries on the record of service for these dates.
Client #3 was admitted on April 3, 2022 and is currently an active client. There was no record of services documented in client record #3.
Client #4 was admitted on April 6, 2022 and is a current client. Progress notes were documented for individual and group sessions on April 8, 9, 11, 12, 13, 14, 15, 17, 18, and 19, 2022. There were no corresponding entries on the record of service for these dates.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the January 2021, May 2021, and January 2022 licensing inspections.
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Plan of Correction
WR by policy requires that a service plan be completed on all clients that documents record of service. Staff did not follow the policy. The procedure has been amended to specifically require the case counselor to complete the service record of clients on their assigned case load each shift. The facility director is responsible for reviewing all charts weekly during the CQI meeting to monitor policy compliance. |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document a follow up contact for referred clients within seven days of discharge, per agency policy, in two of two residential client records.
Client #5 was admitted on February 16, 2022 and was discharged March 15, 2022.
Client #6 was admitted on February 17, 2022 and was discharged on April 5, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
WR by policy requires 7 and 30 day follow-up on all discharged clients. The facility Director is responsible for ensuring completion and on-going compliance of the follow-up policy. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of administrative information, client records, and personnel records, the facility failed to comply with plans of correction that were approved by the Department.
Plans of correction for a complete written procedure for the management of treatment/rehabilitation services for clients were submitted and approved by the Department for the May 2021 and January 2022 licensing inspections. Written procedures for the management of treatment/rehabilitation services for clients were again found to be a deficiency in the April 2022 licensing inspection.
Plans of correction for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, were submitted and approved by the Department for the May 2020, May 2021 and January 2022 licensing inspections. The annual financial audit of activities associated with the project ' s drug/alcohol abuse services was again found to be a deficiency in the April 2022 licensing inspection.
Plans of correction for a consent to release information to be signed prior to disclosure were submitted and approved by the Department for the May 2020, May 2021 and January 2022 licensing inspections. The consent to release information signed prior to disclosure was again found to be a deficiency in the April 2022 licensing inspection.
Plans of correction for documenting the name of the person, agency, or organization on the signed consent to release information form were submitted and approved by the Department for the May 2020, May 2021 and January 2022 licensing inspections. The name of the person, agency, or organization on the signed consent to release information was again found to be a deficiency in the April 2022 licensing inspection.
Plans of correction for documenting the specific information to be disclosed on the signed consent to release information form were submitted and approved by the Department for the May 2020, May 2021 and January 2022 licensing inspections. The specific information to be disclosed on the signed consent to release information was again found to be a deficiency in the April 2022 licensing inspection.
Plans of correction for documenting the purpose of disclosure on the signed consent to release information form were submitted and approved by the Department for the May 2020, May 2021 and January 2022 licensing inspections. The purpose of the disclosure on the signed consent to release information was again found to be a deficiency in the April 2022 licensing inspection.
Plans of correction for offering the client a copy of the consents were submitted and approved by the Department for the May 2021 and January 2022 licensing inspections. Offering the client a copy of the consents were again found to be a deficiency in the April 2022 licensing inspection.
Plans of correction for record of service for the residential clients were submitted and approved by the Department for the January 2021, May 2021 and January 2022 licensing inspections. The record of service for the residential clients were again found to be a deficiency in the April 2022 licensing inspection.
Plans of correction for each counselor meeting the educational and experiential requirements for the position were submitted and approved by the Department for the May 2021 and January 2022 licensing inspections. Counselor qualifications were again found to be a deficiency in the April 2022 licensing inspection.
Plans of correction for documenting written acknowledgement by clients that they have been notified of client rights were submitted and approved by the department for the May 2021 and January 2022 licensing inspections. Written acknowledgement by clients notifying of their rights were again found to be a deficiency in the April 2022 licensing inspection.
Plans of correction for documenting written acknowledgement by clients that they have been notified of who may temporarily remove portions of the records prior to the inspection by the client were submitted and approved by the department for the May 2021 January 2022 licensing inspections. Written acknowledgement by clients notifying of their rights were again found to be a deficiency in the April 2022 licensing inspection.
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Plan of Correction
WR has formed a CAP compliance committee that consists of the facility owner, medical director, nursing director, facility director and project director to oversee the reorganization of the policy and procedure manual, staff training on the CAP policies and noted deficiencies along with monitoring on-going compliance with CAPs. This committee meets formally each week. The facility now has a new Policy and Procedure Manual available for review and a designed computer and office area that contains required inspection documents. The facility is in the process of contracting with an EMR vendor for enhanced client records and paper work reduction that will be organize material for DDAP and other regulatory inspections. The Project Director is responsible for the committee activities and monitoring the compliance with all CAPs that are submitted. |