INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on October 12, 2023 through October 13, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Huntingdon Valley Comprehensive Treatment 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of eight personnel records, the facility failed to maintain documentation that counselor assistants received direct observation of the provision of counseling services as part of their close supervision, in one applicable record.
Employee # 7 was hired by the facility on November 7, 2022 as a counselor assistant, prior to being promoted to the position of counselor on May 10, 2023. During the period of time the employee was a counselor assistant, the supervision notes provided at the time of the inspection did not indicate that direct observation of the provision of counseling services was a part of the close supervision.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinic Director and Clinical Supervisor to meet on 11/6/23 to review §704.9(c) regulations and crosswalk such against what was completed ensuring all counselor assistant responsibilities and supervision of such are accurately documented and evident as to their completion.
Clinic Director will complete reviews during weekly supervision of documentation completed by the Clinical Supervisor, or Lead Counselor, for the Counselor Assistant, to ensure accurate and consistently clear documentation, including direct supervision via observation of clinical engagements, is completed.
During regular supervision such will be reviewed if/when any new counselor assistants are hired.
Monthly reviews by the CD via the monthly scorecard, will provide an additional monitoring of continued compliance to this regulation.
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of eight personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that one employee received the minimum of 4 hours of TB/STD training within the regulatory timeframe.
Employee # 5 was hired as a counselor on April 18, 2022 and was due to have the TB/STD training no later April 18, 2023. However, there was no documentation of the completion of the TB/STD training as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinic Director and Clinical Supervisor will meet with all counselors to educate on mandatory training hours that must be completed, regardless of employment status (full time vs part time).
Clinic Director will present to staff the ability to use PA-TRAIN as an option to complete HIV/AIDS and TB/STD trainings along with other options to assist in timely completion.
Employee #5 will complete the training by 11/29/23
Monthly reviews of staff training checklists will be discussed during individual and group supervision. A review of Training requirements and staff completions will be part of Monthly Staff meeting agendas and reviewed on a Quarterly basis.
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of one applicable record.
Employee # 4 has been in the position of counselor since October 7, 2019. The facility's training year that was reviewed was from January 2022 through December 2022. Employee # 4's personnel record only documented 22.46 hours of training for the period reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinic Director and Clinical Supervisor will meet with all counselors to educate on mandatory training hours that must be completed, regardless of employment status (full time vs part time).
Director and Supervisor will closely monitor all staff and their training hours to ensure that they are compliant with regulations.
Monthly reviews of staff training checklists will be discussed during individual and group supervision. A review of Training requirements and staff completions will be part of Monthly Staff meeting agendas and reviewed on a Quarterly basis.
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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential 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
The facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room, as an individual session in the office C-9 could be heard clearly in office C-10, the room next door, between 10:30 a.m. and 11:00 a.m. on October 12, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinic Director will purchase sound machines and ensure all are placed appropriately throughout the facility including within counseling offices to ensure greater privacy for all engagements in concert to §705.23(3) regulations.
Such will be in place by 12/1/23.
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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 nine client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in seven records reviewed.
Client # 1 was admitted on June 8, 2023 and was active at the time of the inspection. Per a discussion with the Facility Director, information such as client progress was disclosed to the funding source, however, the consent to release information form to the funding source signed by the client on June 8, 2023, did not allow for the release of that information.
Client # 2 was admitted on June 5, 2023 and was discharged on October 4, 2023. The record did not contain an informed and voluntary consent form to the funding source; however, there was evidence of billing.
Client # 3 was admitted on August 31, 2023 and was active at the time of the inspection. Per a discussion with the Facility Director, information such as client progress was disclosed to the funding source, however, the consent to release information form to the funding source signed by the client on August 31, 2023, did not allow for the release of that information.
Client # 4 was admitted on March 10, 2022 and was discharged on August 21, 2023. Per a discussion with the Facility Director, information such as client progress was disclosed to the funding source, however, the consent to release information form to the funding source signed by the client on March 10, 2022, did not allow for the release of that information.
Client # 6 was admitted on December 29, 2022 and was active at the time of the inspection. Per a discussion with the Facility Director, information such as client progress was disclosed to the funding source, however, the consent to release information form to the funding source signed by the client on December 29, 2022, did not allow for the release of that information.
Client # 7 was admitted on February 2, 2023 and was active at the time of the inspection. The record contained documentation of a disclosure of information to a government agency on September 6, 2023, and the record contained no client signed consent to release information form to the agency.
Client # 9 was admitted on March 1, 2023 and was active at the time of the inspection. Per a discussion with the Facility Director, information such as client progress was disclosed to the funding source, however, the consent to release information form to the funding source signed by the client on March 1, 2023, did not allow for the release of that information.
This is a repeat citation from the January 13, 2022 and November 17, 2022 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinic Director and Clinical Supervisor will review consent process with all staff during regular Monthly Staff meetings.
Trainings will be provided to all staff, including all intake staff, as to the proper completion of and adherence to necessary ROI's for any and all parties to whom disclosure is required; this includes patient signed consent upon intake for all funding sources.
Clinical Supervisor will review during End of Day Counselor Checklist submissions as well as during regular weekly chart audits and group supervision.
Clinic Director and Admin. Asst. will review for fiscal ROI's during weekly reviews of all admissions for the week.
All charts cited will be updated by 12/1/23. Initial Training and review will be conducted for all staff by 11/7/23.
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709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on the review of the Unusual Incident records, the facility failed to file a written unusual incident report with the Department within three business days following an unusual incident involving the presence of police, fire, or ambulance personnel onsite.
There was documentation of police personnel at the facility on November 22, 2022; however, there was no documentation that a written unusual incident report was filed with the Department.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Clinic Director to ensure that DDAP is notified by Unusual Incident report when any event occurs with emergency personnel being present.
Any time emergency personnel are called to the clinic, following the internal incident report being filed and Director being notified, Director will immediately report incident to DDAP.
November 22, 2022 incident to be reported by 11/21/23.
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715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on the review of three months of physician and physician assistant timesheets, the facility failed to provide at least one hour of physician time a week on site for every ten patients in three weeks reviewed.
During the week of May 21, 2023 through May 27, 2023, the patient census was 368. The facility was required to provide at least 36.8 physician hours. There were 31 hours documented.
During the week of August 27, 2023 through September 2, 2023, the patient census was 364. The facility was required to provide at least 36.4 physician hours. There were 23 hours documented.
During the week of September 3, 2023 through September 9, 2023, the patient census was 363. The facility was required to provide at least 36.3 physician hours. There were 22 hours documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinic Director will meet with Medical Director by 12/11/2023 to review process for medical coverage in case of absence by either a doctor or Physician assistant.
This discussion will include development of coverage with partnering CTC's. This will be presented to the Regional Director along with the review of the MD Tracking sheet previously created.
Clinic Director to ensure that there is medical coverage during all vacations of medical personnel.
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715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on a review of eight patient records, the facility failed to ensure that emergency contact information was obtained in one record reviewed.
Patient # 3 was admitted on August 31, 2023 and was active at the time of the inspection. The record did not contain emergency contact information.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinic Director and Clinical Supervisor will review consent process with all staff during regular Monthly Staff meetings.
Trainings will be provided to all staff, including all intake staff, as to the proper completion of and adherence signed consents for emergency contact to be signed at time of intake.
Presentation and request will be made to all patients needing to have a signed emergency contact. Any refusal by Pt. will be documented accordingly in the Pt. record.
Clinical Supervisor will review during End of Day Counselor Checklist submissions as well as during regular weekly chart audits and group supervision.
All charts cited will be updated by 12/1/23. Training of all staff to occur by 11/7/23.
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715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of patient records the facility failed to provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy in four of six applicable records.
Patient # 1 was admitted on June 8, 2023 and was active at the time of the inspection. The patient was required to have an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. The patient did not receive any individual therapy during the months of July and August 2023.
Patient # 2 was admitted on June 5, 2023 and was discharged on October 4, 2023. The patient was required to an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. The patient did not receive any individual therapy during the month of August 2023, and only 45 minutes of individual therapy during July 2023.
Patient # 3 was admitted on August 31, 2023 and was active at the time of the inspection. The patient was required to have an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. The patient did not receive a total of 2.5 psychotherapy hours during September 2023.
Patient # 6 was admitted on December 29, 2022 and was active at the time of the inspection. The patient was required to have an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. The patient did not receive any individual therapy during August 2023 and only 30 minutes in each of August and June 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor is working with all staff on implementing new process to ensure fluid communication and accountability are documented in Pt. record as to barriers to meeting treatment expectations.
This procedure includes making sure that patient's treatment plan accurately reflects what the patient should be and/or is doing in regards to therapy. The procedure also includes documenting no shows and a general note at the end of the month documenting why patient has not met their required hours and what the plan is to get them back on track; i.e. treatment agreement.
All staff to be re-trained and re-educated regarding procedure by 11/7/23.
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715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the receiving narcotic treatment program failed to document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose in two of three applicable records reviewed.
Patient # 3 was admitted on August 31, 2023 and was active at the time of the inspection. There was no documentation that the transferring narcotic treatment program was notified.
Patient # 6 was admitted on December 29, 2022 and was active at the time of the inspection. There was no documentation that the transferring narcotic treatment program was notified.
This is a repeat citation from the November 17, 2022 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinic Director and Clinical Supervisor will provide a training by
11/28/23 for transfer processes between OTP's for continued maintenance, detoxification or
another treatment activity.
The training will review the requirement that a transfer acknowledgement
form has been documented in the
EMR and that the transferring program has been notified of completed transfer in a timely manner.
Monthly reviews of any/all transfer
patients will be completed to ensure documented
compliance to regulation §715.20(4).
Ongoing compliance with this regulation will be monitored utilizing
the quality record review process which will be analyzed monthly at
the program level by the clinical supervisor and CTC Director. The
Clinical Supervisor will address non-compliance in this area during
individual supervision.
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715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on a review of patient records, the facility failed to ensure an annual physical reevaluation in two of three applicable records reviewed.
Patient # 4 was admitted on March 10, 2022 and was discharged on August 21, 2023. The annual physical evaluation was due no later than March 10, 2023; however, it was not documented in the patient record until March 27, 2023.
Patient # 5 was admitted on January 16, 2019 and was discharged on May 30, 2023. The annual physical evaluation was due no later than January 16, 2023; however, it was not documented in the patient record until February 6, 2023.
This is a repeat citation from the January 13, 2022 and November 17, 2022 annual licensing renewal inspections.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A mandatory training for medical staff will
be provided by the Director by 12/4/23 to review Medical personal compliance expectations to all Annual Medical
Assessments/Physical Assessment being scheduled a minimum of two weeks prior to the
scheduled due date in the EMR to ensure that completion of the
required documentation is timely.
The Clinic Director will review the services due report in the EMR a
minimum of once per week with CTC
leadership to ensure patients are scheduled for and complete their
annual physicals timely. Charge nurse will monitor, weekly, for the
completion of annual physical examinations, along with Medical
Director.
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715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on a review of patient records, the facility failed to ensure an annual evaluation of each patient ' s status was completed by the patient ' s counselor in two of three applicable records reviewed.
Patient # 4 was admitted on March 10, 2022 and was discharged on August 21, 2023. An annual clinical evaluation was due to be completed by March 10, 2023, however, the annual clinical evaluation was not completed until April 26, 2023.
Patient # 8 was admitted on April 20, 2020 and was discharged on June 3, 2023. An annual clinical evaluation was due to be completed by April 20, 2023, however, the most recent annual clinical evaluation was completed on April 21, 2022.
This is a repeat citation from the January 13, 2022 and November 17, 2022 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A mandatory training for clinical staff will
be provided by the Director by 12/5/23 to review compliance expectations to all Annual Clinical Evaluations being scheduled a minimum of two weeks prior to the
scheduled due date in the EMR to ensure that completion of the
required documentation is timely.
The Clinic Director will review the services due report in the EMR a
minimum of once per week with CTC
leadership to ensure patients are scheduled for and complete their
annual evaluations timely. Clinical Supervisor will monitor, weekly, for the
completion of annual clinical evaluations.
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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 client records and the facility's policies and procedures, the facility failed to document a psychosocial evaluation within seven days of admission, per policy, in six of six applicable records reviewed.
Client # 1 was admitted on June 8, 2023 and was active at the time of the inspection. The psychosocial evaluation was not completed until October 3, 2023.
Client # 2 was admitted on June 5, 2023 and was discharged on October 4, 2023. The psychosocial evaluation was not completed until June 30, 2023.
Client # 3 was admitted on August 31, 2023 and was active at the time of the inspection. The psychosocial evaluation was not completed until September 19, 2023.
Client # 6 was admitted on December 29, 2022 and was active at the time of the inspection. The psychosocial evaluation was not completed until January 23, 2023.
Client # 7 was admitted on February 2, 2023 and was active at the time of the inspection. The psychosocial evaluation was not completed until February 24, 2023.
Client # 9 was admitted on March 1, 2023 and was active at the time of the inspection. The psychosocial evaluation was not completed until April 19, 2023.
These finding were discussed with facility staff during the licensing process.
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Plan of Correction
A mandatory training for all staff will be provided by the Director and Clinical Supervisor by
11/28/23 which will review ALL documentation requirements and timelines.
Director will also meet with Supervisor on working to get patients assigned to a counselor in a more timely manner or working to get the assessments completed timely if no counselor is available.
Director and Supervisor will monitor all admissions weekly to ensure that pts have been assigned to a clinician and all paperwork is completed.
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709.92(a) 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:
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Observations
Based on a review of nine client records, the facility failed to ensure that an individual treatment and rehabilitation plan was developed with the client within 30 days of admission, per the facility policy, in five of six applicable records reviewed.
Client # 1 was admitted on June 8, 2023 and was active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by July 8, 2023; however, it was not completed until August 25, 2023.
Client # 2 was admitted on June 5, 2023 and was discharged on October 4, 2023. The individual treatment and rehabilitation plan was due to be completed by July 5, 2023; however, it was not completed until September 1, 2023.
Client # 6 was admitted on December 29, 2022 and was active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by January 29, 2023; however, it was not completed until February 22, 2023.
Client # 7 was admitted on February 2, 2023 and was active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by March 4, 2023; however, it was not completed until May 1, 2023.
Client # 9 was admitted on March 1, 2023 and was active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by April 1, 2023; however, it was not completed until June 7, 2023.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A mandatory training for all staff will be provided by the Director and Clinical Supervisor by
11/21/23 which will review ALL documentation requirements and timelines.
Director will also meet with Supervisor on working to get patients assigned to a counselor in a more timely manner or working to get the treatment plans completed timely if no counselor is available. Will also utilize Lead Counselor if needed.
Director and supervisor will review all admissions weekly to ensure that treatment plans are completed timely
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709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include case consultation information quarterly for the first year and annually thereafter, per facility policy, in four of eight applicable records reviewed.
Client # 1 was admitted on June 8, 2023 and was active at the time of the inspection. The first case consultation was due to be completed by September 8, 2023; however, it was not completed until October 12, 2023.
Client # 4 was admitted on March 10, 2022 and was discharged on August 21, 2023. A case consultation was documented on September 20, 2022, and the next case consultation was due to be completed by December 2022, however, the next case consultation was not completed until April 7, 2023.
Client # 7 was admitted on February 2, 2023 and was active at the time of the inspection. A case consultation was documented on May 3, 2023, and the next case consultation was due to be completed by August 3, 2022, however, the next case consultation was not completed until August 22, 2023.
Client # 9 was admitted on March 1, 2023 and was active at the time of the inspection. A case consultation was documented on June 1, 2023, and the next case consultation was due to be completed by September 1, 2023, however, no additional case consultation information was documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
A mandatory training for all staff will be provided by the Director and Clinical Supervisor by
11/21/23 which will review ALL documentation requirements and timelines.
Clinical supervisor will review in weekly supervision with counselors their services due and ensure that paperwork is getting completed timely and address any barriers to getting paperwork completed.
Director and Supervisor will review end of day checklists with each clinician daily. Completion Date:
Status:
No POC
Date:
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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 obtaining client signed consent to release information forms prior to disclosures of information was submitted and approved by the Department for the January 13, 2022, and November 17, 2022, annual licensing inspections. Obtaining client signed consent to release information forms prior to disclosing information was again found to be a deficiency in the October 12, 2023 through October 13, 2023 licensing inspection.
A plan of correction for completing patient physicals annually was submitted and approved by the Department for the January 13, 2022, and November 17, 2022, annual licensing inspections. Annual physicals were again found to be a deficiency in the October 12, 2023 through October 13, 2023 licensing inspection.
A plan of correction for completing annual clinical evaluations was submitted and approved by the Department for the January 13, 2022, and November 17, 2022, annual licensing inspections. Annual clinical evaluations were again found to be a deficiency in the October 12, 2023 through October 13, 2023 licensing inspection.
A plan of correction for notifying transferring facilities was submitted and approved by the Department for the November 17, 2022, annual licensing inspection. Notifying transferring facilities was again found to be a deficiency in the October 12, 2023 through October 13, 2023 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
Clinic Director and Clinical supervisor to educate and train new staff on all policies and timelines as noted.
Director to follow up on POC in a more diligent manner and work with staff to ensure that all corrections are made.
POC corrective measures will be part of each Monthly Staff meeting Agenda, to offer review and training opportunities for existing and any new staff members.
As need is identified, individual staff will be assigned additional training opportunities via external or internal means.
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