INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 16, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Holcomb Associates, 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 (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 the physical plant inspection conducted on 5/16/18, it was discovered that the facility failed to maintain client records in locked storage containers at all times. Four client records were found in Room C-1, a counselor's office. The door to the office was opened, unlocked, and unoccupied.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 5/17/18, Clinical Coordinator addressed this with all staff. Coordinator reminded staff to not leave client records on their desks and to maintain client records in a locked storage. In addition, staff were also informed to lock their computers any time they leave their office, in order to support confidentiality of client records.
Moving forward, the Clinical Coordinator will routinely check offices to ensure that client records are not left in clinician's offices. At the end of each day, any paper charts/files will be returned to the locked chart room
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of 7 client records, 6 client records had treatment plan updates completed after the regulatory timeframe or missing at the time of the inspection.
Client #1 was admitted on 9/18/17 and was active at the time of inspection. A treatment plan update was completed 12/20/17 and the next update was due no later than 2/20/18. However, the update was not completed until 3/19/18.
Client #2 was admitted on 1/13/17 and was active at the time of inspection. A treatment plan update was completed 2/23/17 and the next update was due no later than 4/23/17. However, the update was not completed until 5/23/17. Additionally, the next update was due no later than 7/23/17. However, that treatment plan update was not completed until 8/10/17.
Client #3 was admitted on 4/6/17 and was active at the time of inspection. A treatment plan update was completed 5/30/17 and the next update was due no later than 7/30/17. However, the update was not completed until 8/22/17. Additionally, another treatment plan update was completed 10/31/17 and the next update was due no later than 12/31/17. However, that treatment plan update was not completed until 1/23/18.
Client #5 was admitted on 11/7/17 and was discharged on 3/12/18. The comprehensive treatment plan was completed 12/27/17 and an update was due no later than 2/27/18. However, the update was not completed as of the date of the inspection.
Client #6 was admitted on 2/23/17 and was discharged on 10/11/17. The comprehensive treatment plan was completed 2/27/17 and the next update was due no later than 4/27/17. However, the update was not completed until 6/26/17. Additionally, the next update was due no later than 6/26/17. However, that update was not completed as of the date of the inspection.
Client #7 was admitted on 7/20/17 and was discharged on 1/30/18. The comprehensive treatment plan was completed 8/24/17 and the next update was due no later than 10/24/17. However, the update was not completed until 11/24/17.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 5/17/18 Coordinator reviewed treatment plan updates and submission with all staff members. Staff will continue to submit a treatment plan update, even if a client is not engaging. An administrate note will also be entered to reflect the update being submitted without a client signature. Staff were also made aware that even if a client is approaching discharge, if a treatment plan update is due, it must will be submitted to maintain timely submission.
A spreadsheet has been created and implemented for the program that tracks the dates for treatment plan updates. The Coordinator updates this spreadsheet as treatment plan updates are submitted. As well as provide copies of this spreadsheet to clinicians at least bi weekly.
In addition, the Coordinator will review due dates individually with each staff person on a bi-weekly. Any forms of non-compliance to timely treatment plan completion will be addressed through corrective action.
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