INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 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, Little Creek 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 client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in one of fourteen client records reviewed.
Client # 12 was admitted to the outpatient activity on May 9, 2023 and was discharged on July 18, 2023. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In a Clinical Team Meeting on 9/26, the requirement that an ROI be signed for the funding source at the time of admission, was reviewed with the Clinical Team. This has been reiterated at subsequent weekly clinical team meetings. Monthly chart audits will continue to occur and this particular issue will be checked in each chart. |
709.28 (c) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom the disclosure is made to on a consent to release information form in one of fourteen client records reviewed.
Client # 10 was admitted to the outpatient activity on January 23, 2023 and was still active at the time of the inspection. A release of information form to another treatment provider was signed by the client on March 10, 2023; however, the form did not include the name of a person, agency, or organization to whom the disclosure would be made to.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In a Clinical Team meeting on 9/26/23, the proper completion of ROI's was reviewed with the clinical team. Specifically, the requirement that we must provide as much detailed information about the entirety the form is written for, including methods of contact, names, addresses, etc, were all reviewed. This was reiterated in subsequent bi-weekly team meetings and will be followed up on in routine chart audits. A new, correctly completed ROI for this entity and client will be completed in the client's next session on 10/26/23. |
709.28 (c) (3) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of the disclosure on release of information forms in four of fourteen client records reviewed.
Client # 3 was admitted to the partial hospitalization activity on August 16, 2023 and was still active at the time of the inspection. A release of information form to an individual was signed by the client on August 16. 2023, but the form did not include the purpose of the disclosure.
Client # 5 was admitted to the partial hospitalization activity on February 20, 2023 and was discharged on March 19, 2023. Release of information forms to the funding source and two family members were signed by the client on February 20, 2023, but none of the forms included the purpose of the disclosure. Additionally, a release of information form to another treatment provider was signed by the client on March 7, 2023, but the form did not include the purpose of the disclosure.
Client # 7 was admitted to the partial hospitalization activity on June 19, 2023 and was discharged on July 5, 2023. A release of information form to a family member was signed by the client on August 16. 2023, but the form did not include the purpose of the disclosure.
Client # 9 was admitted to the outpatient activity on March 20, 2023 and was still active at the time of the inspection. Release of information forms to the funding source and two family members were signed by the client on February 20, 2023, but none of the forms included the purpose of the disclosure. Additionally, A release of information form to another treatment provider was signed by the client on March 7, 2023, but the form did not include the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
in a Clinical Team meeting on 9/26/23, the correct and thorough completion of ROI's was reviewed with the clinical team. Specifically, the components and sections of the form were each reviewed with counselors. This has been reviewed in bi-weekly team meetings and ROI's will continue to be reviewed for all new admissions in routine monthly chart audits.
Re: Client #3, a new ROI has been created to include purpose.
Re: Client #5, this client has been discharged and had not been back to treatment since the inspection.
Re: Client #7, this client had already been discharged at the time of the inspection.
Re: Client #9, this client has been discharged and had not been back to treatment since the inspection.
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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 a review of client records, the facility failed to document that a copy of a client consent to release information form was offered to the client in fourteen of fourteen client records reviewed.
In every client record reviewed, there was no documentation that a copy of all release of information forms were offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It was determined that there was no method for clients to verify that they were offered a copy of signed ROI's. A checkbox was added to our stock ROI form in our EMR and this section will need to be completed for each ROI that is signed. This was reviewed with the clinical team in a meeting on 9/26/23 and this will continue to be checked/followed-up on through the use of monthly routine chart audits. |
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 document the written acknowledgement by clients that they have been notified of their right that the project may not discriminate in the provision of services on the basis of age, creed, color, or national origin in fourteen of fourteen client records reviewed.
Every client record reviewed had a client-signed client rights acknowledgement form; however, each form was missing this regulatory client right.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The language in DDAP's regulation on Client Rights was copied and pasted into our Client Rights and Responsibilities form. The language is now directly in line with the regulation. This edit was made on 9/25/23 and charts will continue to be reviewed monthly. |
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 document the written acknowledgement by clients that they have been notified of their right to inspect their own records and that 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 and that reasons for removing sections shall be documented in the record in fourteen of fourteen client records reviewed.
Every client record reviewed had a client-signed client rights acknowledgement form; however, each form was missing this regulatory client right.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The language in DDAP's regulation on Client Rights was copied and pasted into our Client Rights and Responsibilities form. The language is now directly in line with the regulation. This edit was made on 9/25/23 and charts will continue to be reviewed monthly. |
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 document the written acknowledgement by clients that they have been notified of their right to submit rebuttal data or memoranda to their own records in fourteen of fourteen client records reviewed.
Every client record reviewed had a client-signed client rights acknowledgement form; however, each form was missing this regulatory client right.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The language in DDAP's regulation on Client Rights was copied and pasted into our Client Rights and Responsibilities form. The language is now directly in line with the regulation. This edit was made on 9/25/23 and charts will continue to be reviewed monthly. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of the decision to involuntarily terminate the client's treatment at the project, including the reason for termination, in one of one applicable client record reviewed.
Client # 7 was admitted to the partial hospitalization activity on June 19, 2023 and was administratively discharged on July 5, 2023. The client was notified in writing of the facility's decision to involuntarily terminate the client's treatment at the project on July 5, 2023; however, the written notice did not include the reason for termination.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Therapeutic Discharge form that is reviewed and signed off on by clients prior to their discharge was edited to require a reason for the discharge. This was not previously a required part of the form and now it is. The form cannot be completed and signed without this information. This change to the form was made on 10/2/23. All Therapeutic Discharged clients' charts will be audited by the Clinical Director or Lead Counselor to assure we are completing this form properly. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to review and update treatment and rehabilitation plans at least every sixty days in three of four applicable client records reviewed.
Client # 9 was admitted to the outpatient activity on March 20, 2023 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on March 17, 2023 and an update was due no later than May 17, 2023; however, the update was not completed at the time of the inspection.
Client # 10 was admitted to the outpatient activity on March 20, 2023 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on February 2, 2023 and an update was due no later than April 2, 2023; however, the update was not completed until April 14, 2023. Additionally, a treatment plan update was completed on April 14, 2023 and an update was due no later than June 14, 2023; however, the update was not completed until July 20, 2023.
Client # 12 was admitted to the outpatient activity on March 20, 2023 and was discharged on July 18, 2023. The individual treatment and rehabilitation plan was completed on May 9, 2023 and an update was due no later than July 9, 2023; however, the update was not completed at discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In a Clinical Team meeting on 9/26/23, the requirements around treatment planning and treatment plan reviews and updates were reviewed. Clinicians all verified that they understand the requirements. The compliance with treatment plan requirements will continue to be reviewed via routine monthly chart audits.
Re: Client #9, this client was discharged and had not been back for a session since the inspection.
Re: Client #10, TX plans have now been updated according to the required time-frames per LOC.
Re: Client #12, this client was discharged and had not been back for a session since the inspection.
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