INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 13, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection CORA Services, Inc., was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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705.29 (2) (iii) LICENSURE Child care.
705.29. Child care.
When a nonresidential facility admits children for services or for custodial care, the following requirements apply:
(2) Interior space. The nonresidential facility shall:
(iii) Maintain protective caps over each electrical outlet.
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Observations
Based on a physical plant inspection on September 13, 2024, the facility failed to maintain protective caps over each electrical outlet as the outlet in office 222, did not have protective caps.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project director alerted the agency's facilities coordinator that protective caps were observed to be missing from outlets in office 222. On 9/16/24, agency facilities staff replaced missing protective caps to office 222 and placed an order for additional protective caps to ensure each office has backup protective caps in the event of protective caps being misplaced. Agency facilities staff completed a full inspection of all electrical outlets in offices and confirmed protective caps were inserted in all electrical outlets as of 9/20/24. Project director will ensure agency facility coordinator will conduct quarterly room/office inspections to ensure all protective caps are covering electrical outlets. |
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 facility failed to obtain an informed and voluntary consent to release information form from the client for the disclosure of information in one record reviewed.
Client # 6 was admitted on April 15, 2024 and was active at the time of the inspection. There was evidence of a disclosure to a family member during a family counseling session on September 11, 2024; however, there was no consent to release information form signed by the client documented in the record prior to the disclosure.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Regarding client #6, it was determined that the counselor obtained an appropriately signed release for disclosure to client's mother; however, the counselor only documented verbal consent for release of information for father, reflected in a DAP note dated 5/8/24 in the client file. Project director provided additional training to the counselor on 9/16 on the confidentiality policy, including guidance that each family member should be noted on the consent to release information signed by client or additional releases should be obtained if disclosure to another person/family member would occur throughout the course of services. Project director and Counselor consulted again on 9/25/24 when Counselor confirmed that client signed consent to release information to the father during a session on 9/25/24. Project director will ensure this policy is being implemented by addressing and reviewing in monthly treatment team meetings beginning October 2024. |
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 ensure that treatment and rehabilitation plans are reviewed and updated at least every sixty days in three of six applicable records reviewed.
Client # 2 was admitted on December 14, 2023 and was discharged on June 27, 2024. A treatment plan update was completed on March 4, 2024, and the next treatment plan update was due no later than May 4, 2024; however, no additional treatment plan updates were completed prior to the client ' s discharge.
Client # 4 was admitted on November 14, 2023 and was discharged on April 30, 2024. A treatment plan update was completed on January 30, 2024, and the next treatment plan update was due no later than March 30, 2024; however, no additional treatment plan updates were completed prior to the client ' s discharge.
Client # 6 was admitted on April 15, 2024 and was active at the time of the inspection. A treatment plan update was completed on June 14, 2024, and the next treatment plan update was due no later than August 14, 2024; however, the treatment plan update was not completed until August 28, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Regarding Client #2: It was determined that no additional treatment plan updates were completed prior to discharge. Project director addressed procedures for the review of treatment plans with counselor on 9/16. Counselor indicated the client had not been attending sessions and Project director provided guidance that an update should still be completed to reflect progress towards goals as well as address and identify any challenges with consistent attendance. As this client is discharged, no further action is able to be taken in the client's file.
Regarding Client #4: Project director and counselor met on 9/25/24 to review the client file and were able to view and locate a completed and signed treatment plan update in the client's file dated 3/27/24 with client signature on 4/9/24. There was a missed opportunity on 4/2/24 for the client to sign the update which was reviewed with the counselor. Project director provided training and guidance on procedures for the review of treatment plans as well as ensuring client's review/signature at the first opportunity. As this client is discharged, no further action is able to be taken in the client's file.
Regarding Client #6: Project director met with counselor on 9/25 to address timely treatment plan update completion, submission and review. Counselor acknowledged understanding of procedures for the timely review of treatment plans and intends to review and submit future updates within the required timeframe effective immediately.
For the 3 examples above, Project director provided additional training and guidance on procedures for the review of treatment plans on 9/16 and 9/25. Expectations for timely review and submission are in effect immediately. Effective immediately, Project director will review all treatment plan updates on a monthly basis to ensure plans are reviewed every 60 days. Additionally, Project director will monitor this area of concern during weekly individual supervision with counselor. |