INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, has implemented temporary procedures for conducting an annual renewal inspection. The inspection will be divided into two parts. 1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist. 2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.This report is a result of Part 2, an abbreviated on-site inspection, conducted on February 17, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.Based on the findings of Part 2, an abbreviated on-site inspection, Caron Outpatient Services 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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709.28 (c) 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.
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Observations
Based on a review of seven client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in two records reviewed.Client #1 was admitted on April 20, 2020 and discharged on October 30, 2020. The project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record but confirmed they were billing.Client #2 was admitted on April 14, 2020 and discharged on May 9, 2020. The project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record but confirmed they were billing.These findings were reviewed with the facility during the licensing process.
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Plan of Correction
Staff will be reeducated on the procedures for completion of informed and voluntary consents for all patients being admitted to the program.
The Health Records Management Department will monitor the completion of consents for patients on a weekly basis and will provide a report to the Clinical Supervisor. |
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 seven client records, the project failed to document written acknowledgement by clients that they have been notified of their rights, in two records reviewed. Client #1 was admitted on April 20, 2020 and discharged on October 30, 2020. The project failed to document written acknowledgement by the client that they had been notified of their rights.Client #2 was admitted on April 14, 2020 and discharged on May 9, 2020. The project failed to document written acknowledgement by the clients that they had been notified of their rights.These findings were reviewed with the facility during the licensing process.
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Plan of Correction
An acknowledgement of client's rights form was developed and staff will be trained on the completion of this form. This form will be completed during the patient's first outpatient appointment.
The Health Records Management Department will monitor completion of this form for new admissions on a weekly basis and will provide a report to the Clinical Supervisor.
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709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of seven client records, the facility failed to document intake procedures that included a medical history in two records reviewed. Client #1 was admitted on April 20, 2020 and discharged on October 30, 2020. There was no documentation of a medical history in the record. Client #2 was admitted on April 14, 2020 and discharged on May 9, 2020. There was no documentation of a medical history in the record. These findings were reviewed with the facility during the licensing process.
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Plan of Correction
Staff will be reeducated on the process for completion of the Medical History. The Quality Improvement Department will monitor the completion of the medical history through the completion of chart reviews on a monthly basis. The results of the chart reviews will be reviewed with the Clinical Supervisor. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of seven client records, the facility failed to document intake procedures that included a drug and alcohol history in two records reviewed. Client #1 was admitted on April 20, 2020 and discharged on October 30, 2020. There was no documentation of a drug and alcohol history in the record. Client #2 was admitted on April 14, 2020 and discharged on May 9, 2020. There was no documentation of a drug and alcohol history in the record. These findings were reviewed with the facility during the licensing process.
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Plan of Correction
Staff will be reeducated on the process for completion of the drug and alcohol history. The Quality Improvement Department will monitor the completion of the drug and alcohol history through completion of chart reviews on a monthly basis. The results of the chart reviews will be reviewed with the Clinical Supervisor. |
709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on a review of seven client records, the facility failed to document intake procedures that included consent to treatment in two records reviewed. Client #1 was admitted on April 20, 2020 and discharged on October 30, 2020. There was no documentation of a consent to treatment in the record. Client #2 was admitted on April 14, 2020 and discharged on May 9, 2020. There was no documentation of a consent to treatment in the record. These findings were reviewed with the facility during the licensing process.
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Plan of Correction
Staff will be reeducated on the procedures for completion of the Consent for Treatment for all patients being admitted to the program.
The Health Records Management Department will monitor the completion of consents for patients on a weekly basis and will provide a report to the Clinical Supervisor.
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709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of seven client records, the facility failed to document intake procedures that included a psychosocial evaluation in two records reviewed. Client #1 was admitted on April 20, 2020 and discharged on October 30, 2020. There was no documentation of a psychosocial evaluation in the record. Client #2 was admitted on April 14, 2020 and discharged on May 9, 2020. There was no documentation of a psychosocial evaluation in the record. These findings were reviewed with the facility during the licensing process.
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Plan of Correction
Staff will be reeducated on the process for completion of the psychosocial evaluation. The Quality Improvement Department will monitor the completion of the psychosocial evaluation through completion of chart reviews on a monthly basis. The results of the chart reviews will be reviewed with the Clinical Supervisor. |
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 seven client records, the facility failed to document a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include an aftercare plan.Client #1 was admitted on April 20, 2020 and discharged on October 30, 2020. There was no documentation of an aftercare plan in the record. Client #2 was admitted on April 14, 2020 and discharged on May 9, 2020. There was no documentation of an aftercare plan in the record. Client # 3 was admitted on October 30, 2020 and discharged on February 14, 2021. There was no documentation of an aftercare plan in the record. These findings were reviewed with the facility during the licensing process.
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Plan of Correction
Staff will be reeducated on the process for completion of the aftercare plan. The Quality Improvement Department will monitor the completion of the aftercare plan through completion of chart reviews on a monthly basis. The results of the chart reviews will be reviewed with the Clinical Supervisor. |
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 seven client records, the facility failed to document a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include follow up information.Client #1 was admitted on April 20, 2020 and discharged on October 30, 2020. There was no documentation of follow up information in the record. Client #2 was admitted on April 14, 2020 and discharged on May 9, 2020. There was no documentation of follow up information in the record. Client # 3 was admitted on October 30, 2020 and discharged on February 14, 2021. There was no documentation of follow up information in the record. These findings were reviewed with the facility during the licensing process.
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Plan of Correction
Caron Outpatient Services policy and procedure on the completion of patient follow up was revised and staff will be educated on the revised procedures.
The Quality Improvement Department will monitor the completion of patient follow up calls through completion of chart reviews on a monthly basis. The results of the chart reviews will be reviewed with the Clinical Supervisor. |