INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 5-6, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Arkview Recovery Center 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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705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside of the counseling room as the partial group room door had windows that were not covered. Additionally, the outpatient group room had windows that were not covered and the door was not fully closed allowing the session to be heard from outside.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Maintenance will ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. The blinds, window coating, and sound machine were immediately installed in the area cited. All staff will be trained on the regulation and maintenance request procedure by 8/30/24.
Ongoing monitoring of conformance will occur via monthly Quality Assurance physical plant inspections and meeting review.
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705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to provide either individual paper towels or a mechanical dryer in the men ' s shower room toilet.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Maintenance will ensure that all bathrooms include a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer. A maintenance request for installation of a mechanical hand dryer was submitted and paper towels are available in the area cited until a dryer is obtained. All staff will be trained on the regulation and maintenance request procedure by 9/4/24.
Ongoing monitoring of conformance will occur via monthly Quality Assurance physical plant inspections and meeting review. |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ensure that stairways, hallways and exits from rooms within the residential facility are unobstructed as the group room in the wellness hallway had a chair in front of the exit door.
This findings was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Maintenance, Clinicians, and Behavioral Health Technicians will ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed. The chair that was sitting behind the group room door was promptly removed. All staff and clients will be trained by 9/4/24 on the importance of maintaining unobstructed areas of movement and clear egress.
Ongoing monitoring of conformance will occur via BHT shift rounds and monthly physical plant inspections. |
705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The fire extinguisher in the wellness center hallway did not have a tag indicating when and if the extinguisher was inspected annually.
This findings was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Maintenance will ensure that fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable. The D Hallway fire extinguisher with a missing tag was immediately checked and the tag replaced. All staff and clients will be trained by 9/4/24 on the importance of maintaining tags on fire extinguishers and reporting any needs.
Ongoing monitoring of conformance will occur via monthly physical plant inspections and Quality Assurance meeting reviews. |
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 detox and residential client records, the facility failed to follow the written procedures for the management of treatment/rehabilitation services for clients in two of five applicable client records reviewed.
Per the requirement in the DDAP Licensing Alert 02-21 the emergency contact will be notified no later than 12 hours after a client is discharged from the facility against medical advice
Client # 6 was admitted to the inpatient non-hospital detoxification activity on April 17, 2024, and was discharged against medical advice on April 23, 2024. There was no documentation that the emergency contact was notified of the clients discharge from the facility against medical advice as of the date of the inspection.
Client #13 was admitted to the inpatient non-hospital rehabilitation activity on May 24, 2024 and was discharged against medical advice on May 29, 2024. There was no documentation that the emergency contact was notified of the clients discharge from the facility against medical advice as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will ensure that the emergency contact is notified no less than 12 hours after a client is discharged from the facility against medical advice by designated staff and documented in the client record. All staff will be trained on the regulation and implementation by 9/4/24.
Ongoing monitoring of conformance will occur via monthly Quality Assurance audits and meeting review.
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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 documents and an interview with the facility director, the project failed to document an annual financial audit for the fiscal year ending December 31, 2022 and 2023.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director/CEO will ensure that the project obtains the services of an independent 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 substance treatment activities.
The financial audit will be completed no later than 4/30/25.
In the interim, Arkview has letters of financial review and reports from an independent accounting firm available for reference. An exception request has been submitted.
Ongoing monitoring of conformance will occur via quarterly Quality Assurance meeting. |
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 include the specific information to be disclosed in one of twenty-eight records reviewed.
Client #18 was admitted on May 13, 2024 and was discharged on May 28, 2024 . A release of information form was signed and dated on April 14, 2024 to the emergency contact that failed to include the specific information to be released.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Program Director will ensure that the written client consent to release information includes the specific information to be disclosed. All staff will be trained on the regulation and implementation by 9/4/24.
Ongoing monitoring of conformance will occur via monthly Quality Assurance audits and meeting review.
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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 the review of client records, the facility failed to document a completed consent to release information form which is to include the purpose of the release in one out of twenty-eight records.
Client #8 was admitted on July 1, 2024 and was still active at the time of the inspection. A consent form dated July 1, 2024 to " emergency contact " that failed to include the purpose of the release.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Program Director will ensure that the written client consent to release information includes the purpose of disclosure. All staff will be trained on the regulation and implementation by 9/4/24.
Ongoing monitoring of conformance will occur via monthly Quality Assurance audits and meeting review.
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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 review of client records, the facility failed to document a completed consent to release information form which is to include if the client was offered a copy of the consent form in eight of twenty-eight records reviewed.
Client #11 was admitted on November 30, 2023 and was discharged on January 1, 2024. Consent to release forms were signed and dated November 30, 2023 to the funding source, emergency contact, local hospital and urgent care that failed to include if the client was offered a copy.
Client #12 was admitted on March 18, 2024 and was discharged on April 18, 2024 . Consent to release forms were signed and dated March 19, 2024 to the funding source, emergency contact, local hospital and urgent care that failed to include if the client was offered a copy.
Client #21 was admitted on March 2, 2024 and was discharged on April 26, 2024 . Consent to release forms were signed and dated February 5, 2024 to the funding source, emergency contact, local hospital and urgent care that failed to include if the client was offered a copy.
Client #25 was admitted on January 23, 2024 and was discharged on April 5, 2024. Consent to release forms were signed and dated December 20, 2023 to the funding source, emergency contact, local hospital and urgent care that failed to include if the client was offered a copy.
Client #26 was admitted on December 23, 2023, and was discharged on April 5, 2024. Consent to release forms were signed and dated November 13, 2023, to the funding source, emergency contact, local hospital and urgent care that failed to include if the client was offered a copy.
Client #27 was admitted on March 22, 2024, and was discharged on July 12, 2024. Consent to release forms were signed and dated February 17, 2024, to the funding source, emergency contact, local hospital, urgent care and veteran's affairs that failed to include if the client was offered a copy.
Client #28 was admitted on April 2, 2024 and was discharged on June 10, 2024. Consent to release forms were signed and dated April 2, 2024 to the funding source and emergency that failed to include if the client was offered a copy.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Program Director will ensure that the written client consent to release information includes an indication that the client was offered a copy. The format of the Consent to Release Information document has been revised to include a check box indication of whether the client accepted or declined a copy. All staff will be trained on the regulation and implementation by 9/4/24.
Ongoing monitoring of conformance will occur via monthly Quality Assurance audits and meeting review.
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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
Based on a review of client records, the facility failed to notify clients that they shall retain civil rights and liberties except as provided by statue and no client may be deprived of a civil right solely by reason of treatment in fourteen out of twenty-eight records reviewed
Client #6 was admitted on April 17, 2024 and was discharged on April 23, 2024.
Client #7 was admitted on May 23, 2024 and was discharged on May 28, 2024.
Client #11 was admitted on November 30, 2023 and was discharged on January 1, 2024
Client #12 was admitted on March 18, 2024 and was discharged on April 18, 2024
Client #13 was admitted on May 24, 2024 and was discharged on May 29, 2024.
Client #15 was admitted on April 25, 2024 and was still active at the time of the inspection.
Client #16 was admitted on May 3, 2024 and was still active at the time of the inspection.
Client #19 was admitted on April 5, 2024 and was discharged on May 6, 2024.
Client #21 was admitted on March 12, 2024 and was discharged on April 26, 2024.
Client #23 was admitted on May 20, 2024 and was still active at the time of the inspection
Client #25 was admitted on January 23, 2024 and was discharged on April 5, 2024
Client #26 was admitted on December 26, 2023 and was discharged on April 5, 2024.
Client #27 was admitted on March 22, 2024 and was discharged on July 12, 2024
Client #28 was admitted on April 2, 2024 and was discharged on June 10, 2024.
This finding was reviewed with facility staff during the licensing inspection.
This is a repeat citation from the June 9, 2022 and June 5, 2023 inspection.
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Plan of Correction
The Program Director will ensure that the client records document written acknowledgement by clients that they have been notified of their rights including retention of civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment. The Client Rights document has been revised accordingly. All staff will be trained on the regulation and implementation by 9/4/24.
Ongoing monitoring of conformance will occur via monthly Quality Assurance audits and meeting review.
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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 client records, the facility failed to notify clients that they may not be discriminated against based on ethnicity, marital status, sexual orientation, handicap, or religion in fourteen of the twenty-eight records reviewed.
Client #6 was admitted on April 17, 2024 and was discharged on April 23, 2024.
Client #7 was admitted on May 23, 2024 and was discharged on May 28, 2024.
Client #11 was admitted on November 30, 2023 and was discharged on January 1, 2024
Client #12 was admitted on March 18, 2024 and was discharged on April 18, 2024
Client #13 was admitted on May 24, 2024 and was discharged on May 29, 2024.
Client #15 was admitted on April 25, 2024 and was still active at the time of the inspection.
Client #16 was admitted on May 3, 2024 and was still active at the time of the inspection.
Client #19 was admitted on April 5, 2024 and was discharged on May 6, 2024.
Client #21 was admitted on March 12, 2024 and was discharged on April 26, 2024.
Client #23 was admitted on May 20, 2024 and was still active at the time of the inspection
Client #25 was admitted on January 23, 2024 and was discharged on April 5, 2024
Client #26 was admitted on December 26, 2023 and was discharged on April 5, 2024.
Client #27 was admitted on March 22, 2024 and was discharged on July 12, 2024
Client #28 was admitted on April 2, 2024 and was discharged on June 10, 2024.
This finding was reviewed with facility staff during the licensing inspection.
This is a repeat citation from the June 9, 2022 and June 5, 2023 inspection.
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Plan of Correction
The Program Director will ensure that the client records document written acknowledgement by clients that they have been notified of their rights including non-discrimination in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion. The Client Rights document has been revised accordingly. All staff will be trained on the regulation and implementation by 9/4/24.
Ongoing monitoring of conformance will occur via monthly Quality Assurance audits and meeting review.
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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 client records, the facility failed to notify clients that clients have the right to inspect their own records. The director may temporarily remove portions of their record prior to the inspection by the client and reasons for removing sections shall be documented in fourteen of the twenty-eight records reviewed.
Client #6 was admitted on April 17, 2024 and was discharged on April 23, 2024.
Client #7 was admitted on May 23, 2024 and was discharged on May 28, 2024.
Client #11 was admitted on November 30, 2023 and was discharged on January 1, 2024
Client #12 was admitted on March 18, 2024 and was discharged on April 18, 2024
Client #13 was admitted on May 24, 2024 and was discharged on May 29, 2024.
Client #15 was admitted on April 25, 2024 and was still active at the time of the inspection.
Client #16 was admitted on May 3, 2024 and was still active at the time of the inspection.
Client #19 was admitted on April 5, 2024 and was discharged on May 6, 2024.
Client #21 was admitted on March 12, 2024 and was discharged on April 26, 2024.
Client #23 was admitted on May 20, 2024 and was still active at the time of the inspection
Client #25 was admitted on January 23, 2024 and was discharged on April 5, 2024
Client #26 was admitted on December 26, 2023 and was discharged on April 5, 2024.
Client #27 was admitted on March 22, 2024 and was discharged on July 12, 2024
Client #28 was admitted on April 2, 2024 and was discharged on June 10, 2024.
This finding was reviewed with facility staff during the licensing inspection.
This is a repeat citation from the June 9, 2022 and June 5, 2023 inspection.
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Plan of Correction
The Program Director will ensure that the client records document written acknowledgement by clients that they have been notified of their rights including the right to inspect their own records. The project 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. The Client Rights document has been revised accordingly. All staff will be trained on the regulation and implementation by 9/4/24.
Ongoing monitoring of conformance will occur via monthly Quality Assurance audits and meeting review |
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
Based on a review of client records, the facility failed to notify clients that they have the right to appeal a decision limiting access to their records in fourteen of the twenty-eight records reviewed.
Client #6 was admitted on April 17, 2024 and was discharged on April 23, 2024.
Client #7 was admitted on May 23, 2024 and was discharged on May 28, 2024.
Client #11 was admitted on November 30, 2023 and was discharged on January 1, 2024
Client #12 was admitted on March 18, 2024 and was discharged on April 18, 2024
Client #13 was admitted on May 24, 2024 and was discharged on May 29, 2024.
Client #15 was admitted on April 25, 2024 and was still active at the time of the inspection.
Client #16 was admitted on May 3, 2024 and was still active at the time of the inspection.
Client #19 was admitted on April 5, 2024 and was discharged on May 6, 2024.
Client #21 was admitted on March 12, 2024 and was discharged on April 26, 2024.
Client #23 was admitted on May 20, 2024 and was still active at the time of the inspection
Client #25 was admitted on January 23, 2024 and was discharged on April 5, 2024
Client #26 was admitted on December 26, 2023 and was discharged on April 5, 2024.
Client #27 was admitted on March 22, 2024 and was discharged on July 12, 2024
Client #28 was admitted on April 2, 2024 and was discharged on June 10, 2024.
This finding was reviewed with facility staff during the licensing inspection.
This is a repeat citation from the June 9, 2022 and June 5, 2023 inspection.
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Plan of Correction
The Program Director will ensure that the client records document written acknowledgement by clients that they have been notified of their rights including the right to appeal a decision limiting access to their records to the Director. The Client Rights document has been revised accordingly. All staff will be trained on the regulation and implementation by 9/4/24.
Ongoing monitoring of conformance will occur via monthly Quality Assurance audits and meeting review.
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709.30 (5) 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.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Based on a review of client records, the facility failed to notify clients that they have the right to request correction of inaccurate, irrelevant, outdated or incomplete information in their records in fourteen of the twenty-eight records reviewed.
Client #6 was admitted on April 17, 2024 and was discharged on April 23, 2024.
Client #7 was admitted on May 23, 2024 and was discharged on May 28, 2024.
Client #11 was admitted on November 30, 2023 and was discharged on January 1, 2024
Client #12 was admitted on March 18, 2024 and was discharged on April 18, 2024
Client #13 was admitted on May 24, 2024 and was discharged on May 29, 2024.
Client #15 was admitted on April 25, 2024 and was still active at the time of the inspection.
Client #16 was admitted on May 3, 2024 and was still active at the time of the inspection.
Client #19 was admitted on April 5, 2024 and was discharged on May 6, 2024.
Client #21 was admitted on March 12, 2024 and was discharged on April 26, 2024.
Client #23 was admitted on May 20, 2024 and was still active at the time of the inspection
Client #25 was admitted on January 23, 2024 and was discharged on April 5, 2024
Client #26 was admitted on December 26, 2023 and was discharged on April 5, 2024.
Client #27 was admitted on March 22, 2024 and was discharged on July 12, 2024
Client #28 was admitted on April 2, 2024 and was discharged on June 10, 2024.
This finding was reviewed with facility staff during the licensing inspection.
This is a repeat citation from the June 9, 2022 and June 5, 2023 inspection.
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Plan of Correction
The Program Director will ensure that the client records document written acknowledgement by clients that they have been notified of their rights including the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records. The Client Rights document has been revised accordingly. All staff will be trained on the regulation and implementation by 9/4/24.
Ongoing monitoring of conformance will occur via monthly Quality Assurance audits and meeting review.
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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 client records, the facility failed to notify clients that they have the right to submit rebuttal data or memoranda to their record in fourteen of the twenty-eight records reviewed.
Client #6 was admitted on April 17, 2024 and was discharged on April 23, 2024.
Client #7 was admitted on May 23, 2024 and was discharged on May 28, 2024.
Client #11 was admitted on November 30, 2023 and was discharged on January 1, 2024
Client #12 was admitted on March 18, 2024 and was discharged on April 18, 2024
Client #13 was admitted on May 24, 2024 and was discharged on May 29, 2024.
Client #15 was admitted on April 25, 2024 and was still active at the time of the inspection.
Client #16 was admitted on May 3, 2024 and was still active at the time of the inspection.
Client #19 was admitted on April 5, 2024 and was discharged on May 6, 2024.
Client #21 was admitted on March 12, 2024 and was discharged on April 26, 2024.
Client #23 was admitted on May 20, 2024 and was still active at the time of the inspection
Client #25 was admitted on January 23, 2024 and was discharged on April 5, 2024
Client #26 was admitted on December 26, 2023 and was discharged on April 5, 2024.
Client #27 was admitted on March 22, 2024 and was discharged on July 12, 2024
Client #28 was admitted on April 2, 2024 and was discharged on June 10, 2024.
This finding was reviewed with facility staff during the licensing inspection.
This is a repeat citation from the June 9, 2022 and June 5, 2023 inspection.
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Plan of Correction
The Program Director will ensure that the client records document written acknowledgement by clients that they have been notified of their rights including the right to submit rebuttal data or memoranda to their own records.The Client Rights document has been revised accordingly. All staff will be trained on the regulation and implementation by 9/4/24.
Ongoing monitoring of conformance will occur via monthly Quality Assurance audits and meeting review.
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709.81(b)(7) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document a preliminary treatment plan. The facility's policy and procedures manual states that the preliminary treatment plan must be completed within 24 hours of admission in all seven partial hospitalization records reviewed.
Client #15 was admitted on April 25, 2024 and was still active at the time of the inspection.
Client #16 was admitted on May 3, 2024 and was still active at the time of the inspection.
Client #17 was admitted on June 18, 2024 and was still active at the time of the inspection.
Client #18 was admitted on May 13, 2024 and was discharged on May 28, 2024.
Client #19 was admitted on April 5, 2024 and was discharged on May 6, 2024.
Client #20 was admitted on June 17, 2024 and was discharged on July 8, 2024.
Client #21 was admitted on March 12, 2024 and was discharged on April 26, 2024.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Program Director will ensure that the preliminary treatment and rehabilitation plan is developed with the client within 24 hours of admission and documented in the client record. All clinical staff (and nursing as appropriate) will be trained on the regulation and implementation by 8/30/24.
Ongoing monitoring of conformance will occur via monthly Quality Assurance audits and meeting review |
709.82(a)(3) LICENSURE Treatment and rehabilitation services
709.82. 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:
(3) Proposed type of support service.
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Observations
Based on a review of partial hospitalization client records, the facility failed to document proposed type of support service on individual treatment plans in six out of six client records reviewed.
Client #15 was admitted on April 25, 2024 and was still active at the time of the inspection.
Client #16 was admitted on May 3, 2024 and was still active at the time of the inspection.
Client #17 was admitted on June 18, 2024 and was still active at the time of the inspection.
Client #19 was admitted on April 5, 2024 and was discharged on May 6, 2024.
Client #20 was admitted on June 17, 2024 and was discharged on July 8, 2024.
Client #21 was admitted on March 12, 2024 and was discharged on April 26, 2024.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Program Director will ensure that an individual treatment and rehabilitation plan is developed with the client to include, but not be limited to, written documentation of the proposed type of support service. All clinical staff will be trained on the regulation and implementation by 8/30/24.
Ongoing monitoring of conformance will occur via monthly Quality Assurance audits and meeting review. |
709.82(c) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of partial hospitalization client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plans in four out of five applicable records reviewed.
Client #16 was admitted on May 3, 2024, and was still active at the time of the inspection. The treatment plan dated May 9, 2024 indicated two individual session weekly. The client record indicated that the client only received one individual session weekly since admission.
Client #17 was admitted on June 18, 2024 and was still active at the time of the inspection. The treatment plan dated June 21, 2024 indicated two individual sessions weekly . There was no documentation that the client received two individual sessions weekly July 5, 2024 and July 30, 2024.
Client #19 was admitted on April 5, 2024 and was discharged May 6, 2024. The treatment plan dated April 15, 2024 indicated two individual sessions weekly. The client record indicated that the client only received one individual session weekly for the month of April 2024.
Client #21 was admitted on March 12, 2024 and was discharged April 26, 2024. The treatment plan dated March 27, 2024 indicated two individual sessions weekly . The client record indicated that the client only received one individual session weekly for the month of April 2024.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Program Director will ensure that counseling services are provided according to the individual treatment and rehabilitation plan. All clinical staff will be trained on the regulation and implementation by 8/30/24.
Ongoing monitoring of conformance will occur via monthly Quality Assurance audits and meeting review. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of partial hospitalization client records, the facility failed to provide client with at least two individual sessions weekly in six of six client records reviewed.
Client #15 was admitted on April 25, 2024, and was still active at the time of the inspection. The client record indicated the client only received on individual session weekly since admission.
Client #16 was admitted on May 3, 2024, and was still active at the time of the inspection. The client record indicated that the client only received one individual session weekly since admission.
Client #17 was admitted on June 18, 2024 and was still active at the time of the inspection. There was no documentation that the client received two individual sessions weekly July 5, 2024 and July 30, 2024.
Client #19 was admitted on April 5, 2024 and was discharged May 6, 2024. The client record indicated that the client only received one individual session weekly for the month of April 2024.
Client #20 was admitted on June 17, 2024 and was discharged on July 8, 2024. The client record indicated that the client only received one individual session a week from June 17 2024 until July 8, 2024.
Client #21 was admitted on March 12, 2024 and was discharged April 26, 2024. The client record indicated that the client only received one individual session weekly for the month of April 2024.
These findings were reviewed with facility staff during the licensing inspection
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Plan of Correction
The Program Director will ensure that individual counseling services are provided to a client in the Partial Hospitalization Program on a regular and scheduled basis at least twice weekly, and documented accordingly. All clinical staff will be trained on the regulation and implementation by 8/30/24.
Ongoing monitoring of conformance will occur via monthly Quality Assurance audits and meeting review |
709.83(a)(11) LICENSURE Client records
709.83. 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 record and the facility's policy and procedures which includes a follow up call/survey completed 30 days, 90 days, 180 days, 9 months and 1 year. The facility failed to follow their policy in two out of two applicable records reviewed.
Client #18 was admitted on May 13, 2024 and was discharged on May 28, 2024. No follow-up information was documented.
Client #21 was admitted on March 12, 2024 and was Discharged April 26, 2024. No follow -up information was documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will ensure that the client record includes follow-up contact information within one week of the date a referral is to be completed, when referred outside the organization or within 30 days post discharge if no referral was made. (Not applicable when transitioning internally between levels of care.) Policy and documentation format is being revised. The Alumni Coordinator and clinical staff will be trained on the regulation and implementation by 8/30/24. Ongoing monitoring of conformance will occur via monthly Quality Assurance audits and meeting review.
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709.63(a)(8) LICENSURE Follow-up Information
709.63. 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) Follow-up information.
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Observations
Based on a review of client record and the facility's policy and procedures which includes a follow up call/survey completed 1 week, 90 days, 180 days, 9 months and 1 year. The facility failed to follow their policy in two out of three records reviewed.
Client #5 was admitted on June 14, 2024 and was discharged on June 17, 2024. No follow-up information was documented.
Client #6 was admitted on April 17, 2024 and was discharged on April 23, 2024. No follow-up information was doucmented for 90 days.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will ensure that the client record includes follow-up contact information within one week of the date a referral is to be completed, when referred outside the organization or within 30 days post discharge if no referral was made. (Not applicable when transitioning internally between levels of care.) Policy and documentation format is being revised. The Alumni Coordinator and clinical staff will be trained on the regulation and implementation by 8/30/24.
Ongoing monitoring of conformance will occur via monthly Quality Assurance audits and meeting review |
709.52(a)(3) LICENSURE Support service type
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:
(3) Proposed type of support service.
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Observations
Based on a review of inpatient client records, the facility failed to document proposed type of support service on individual treatment plans in seven out of seven client records reviewed.
Client #8 was admitted July 1, 2024 and was still active at the time of the inspection
Client #9 was admitted on July 2, 2024 and was still active at the time of the inspection.
Client #10 was admitted on July 15, 2024 and was still active at the time of the inspection.
Client #11 was admitted on November 30, 2023 and was discharged on January 1, 2024
Client #12 was admitted on March 18, 2024 and was discharged on April 18, 2024.
Client #13 was admitted on May 24, 2024 and was discharged on May 29, 2024.
Client #14 was admitted on June 9, 2024 and was discharged on June 16, 2024.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Program Director will ensure that the individual and rehabilitation plan includes written documentation of the proposed type of support service. All clinical staff will be trained on the regulation and implementation by 8/30/24.
Ongoing monitoring of conformance will occur via monthly Quality Assurance audits and meeting review.
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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 record and the facility's policy and procedures which includes a follow up call/survey completed 30 days, 90 days, 180 days, 9 months and 1 year. The facility failed to follow their policy in three out of three records reviewed.
Client #12 was admitted on March 18, 2024 and was discharged on April 18, 2024. No follow-up information was documented for 30 or 90 days.
Client #13 was admitted on May 24, 2024 and was discharged on May 29, 2024. No follow- up information was documented.
Client #14 was admitted on June 9, 2024 and was discharged on June 16, 2024. No follow-up information was documented for 30 days.
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These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will ensure that the client record includes follow-up contact information within one week of the date a referral is to be completed, when referred outside the organization, or within 30 days post discharge if no referral was made. (Not applicable when transitioning internally between levels of care.) Policy and documentation format is being revised. The Alumni Coordinator and clinical staff will be trained on the regulation and implementation by 8/30/24.
Ongoing monitoring of conformance will occur via monthly Quality Assurance audits and meeting review.
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709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of outpatient client records, the facility failed to document a preliminary treatment plan. The facility's policy and procedures manual states that the preliminary treatment plan must be completed within 24 hours of admission in six out of six records reviewed.
Client #22 was admitted on May 22, 2024 and was still active at the time of the inspection.
Client #23 was admitted on May 20, 2024 and was still active at the time of the inspection.
Client #24 was admitted on June 5, 2024 and was still active at the time of the inspection.
Client #26 was admitted on December 26, 2023 and was discharged on April 5, 2024.
Client #27 was admitted on March 22, 2024 and was discharged on July 7, 2024.
Client #28 was admitted on April 2, 2024 and was discharged on June 10, 2024
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Program Director will ensure that the preliminary treatment and rehabilitation plan is developed with the client within 24 hours of admission and documented in the client record. All clinical staff will be trained on the regulation and implementation by 8/30/24.
Ongoing monitoring of conformance will occur via monthly Quality Assurance audits and meeting review.
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709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. 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:
(3) Proposed type of support service.
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Observations
Based on a review of outpatient client records, the facility failed to document proposed type of support service on individual treatment plans in all seven records reviewed.
Client #22 was admitted on May 22, 2024 and was still active at the time of the inspection.
Client #23 was admitted on May 20, 2024 and was still active at the time of the inspection.
Client #24 was admitted on June 5, 2024 and was still active at the time of the inspection.
Client #25 was admitted on January 23, 2024 and was discharged on April 5, 2024.
Client #26 was admitted on December 26, 2023 and was discharged on April 5, 2024.
Client #27 was admitted on March 22, 2024 and was discharged on July 7, 2024.
Client #28 was admitted on April 2, 2024 and was discharged on June 10, 2024
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Program Director will ensure that the individual and rehabilitation plan includes written documentation of the proposed type of support service. All clinical staff will be trained on the regulation and implementation by 8/30/24.
Ongoing monitoring of conformance will occur via monthly Quality Assurance audits and meeting review.
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709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of outpatient client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plans in five out of five applicable records reviewed..
Client #22 was admitted on May 22, 2024 and was still active at the time of the inspection. A treatment plan dated May 29, 2024 indicated two individual sessions weekly. The client record indicated the client only reiceved one individual session weekly since admission.
Client #25 was admitted on January 23, 2024 and was discharged on April 5, 2024. The treatment plan dated February 6, 2024 indicated individual sessions weekly. The client record indicated that the client only received individual session on February 6, 2024 and March 5, 2024. There was no documentation for missed sessions.
Client #26 was admitted on December 26, 2023 and was discharged on April 5, 2024. The treatment plan dated February 12, 2024 indicated one individual session weekly . The client record indicated that the client only receive one individual session on February 13, 2024. There was no documentation for missed sessions.
Client #27 was admitted on March 22, 2024 and discharged on July 12, 2024. The treatment plan dated March 26, 2024 indicated one individual session weekly. The client record indicated no individual sessions from May 23, 2024 through June 5, 2024 and no sessions from June 19, 2024 through July 5, 2024. There was no documentation for missed sessions.
Client #28 was admitted on April 2, 2024 and discharge on June 10, 2024 . The treatment plan dated April 9, 2024 indicated one individual session weekly . The client record indicated no individual sessions from May 6, 2024 through May 20, 2024 and no sessions from May 20, 2024 through June 3, 2024.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Program Director will ensure that counseling services are provided and documented according to the individual treatment and rehabilitation plan. All clinical staff will be trained on the regulation and implementation by 8/30/24.
Ongoing monitoring of conformance will occur via monthly Quality Assurance audits and meeting review |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of outpatient client records, the facility failed to provide a complete client record, which is to include aftercare information in two out of four applicable discharged records reviewed.
Client #25 was admitted on January 23, 2024 and was discharged on April 5, 2024.
Client #26 was admitted on December 26, 2023 and was discharged on April 5, 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will ensure that a complete client record includes information related to aftercare planning. In the event that a client refuses aftercare planning, refusal should be documented in the record with notation of any intervention or supportive resources shared. All clinical staff will be trained on the regulation and implementation by 8/30/24.
Ongoing monitoring of conformance will occur via monthly Quality Assurance audits and meeting review.
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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
Based on a review of client record and the facility's policy and procedures which includes a follow up call/survey completed 30 days, 90 days, 180 days, 9 months and 1 year. The facility failed to follow their policy in two out of three records reviewed.
Client #25 was admitted on January 23, 2024 and was discharged on April 5, 2024. No follow-up information was documented for 60 or 90 days.
Client #26 was admitted on December 26, 2023 and was discharged on April 5, 2024. No follow-up information was documented for 60 or 90 days.
.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will ensure that the client record includes follow-up contact information within one week of the date a referral is to be completed, when referred outside the organization or within 30 days post discharge if no referral was made. (Not applicable when transitioning internally between levels of care.) Policy and documentation format is being revised. The Alumni Coordinator and clinical staff will be trained on the regulation and implementation by 8/30/24.
Ongoing monitoring of conformance will occur via monthly Quality Assurance audits and meeting review
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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 client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for informing clients of their rights was submitted and approved by the Department for June 9, 2022 and June 5, 2023 licensing inspections. Client Rights were again found to be a deficiency in the August 5-6, 2024 annual licensing inspection.
This was reviewed with the facility staff during the licensing process.
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Plan of Correction
A new Compliance Coordinator has been appointed to collaborate with the Program Director and Executive Director/CEO to ensure that Arkview Recovery Center conforms with all licensing and regulatory standards and provide ongoing monitoring via monthly Quality Assurance audits. Multiple policies, procedures, documents, and postings, including but not limited to, Client Rights have been reviewed, revised, and distributed to staff and clients to ensure accuracy and consistency in materials and practice. Additionally, the organization's Plan of Correction will be reviewed with all staff by 9/4/24.
Executive leadership and management will share continued administrative oversight for compliance and adherence to the organization's Plan of Correction via quarterly Quality Assurance meetings with timely intervention as needed.
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