INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 24, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, PA Treatment and Healing 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) (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 obtain informed and voluntary consent, which includes the name of person, agency, or organization to whom disclosure is made in one of seven client records reviewed.
Client # 1 was admitted on September 19, 2023, and was still active at that the time of the inspection. A release of information form dated September 19, 2023, was complete in its entirety but it did not specify to whom the information would be released.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
the facility failed to obtain informed and voluntary consent, which includes the name of person, agency, or organization to whom disclosure is made in one of seven client records reviewed.
Client # 1 was admitted on September 19, 2023, and was still active at that the time of the inspection. A release of information form dated September 19, 2023, was complete in its entirety but it did not specify to whom the information would be released.
The Facility Director will meet with all counselors to review policies and procedures for correctly completing all aspects of an appropriate consent including the necessity to specify whom the information will be released to.
The Facility Director, Project Director,
and Lead Counselor will monitor compliance of these standards through continued supervision and quality review of 3 client files from each counselor 1 time per month.
The agency will be in compliance with this standard as of 8/31/2024 |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to obtain a completed informed and voluntary consent which included the dated signature of the client in two out of seven records reviewed.
Client # 1 was admitted on September 19, 2023, and was still active at that the time of the inspection. A release of information dated September 19, 2023, to a single county authority, did not contain a signature or date.
Client #7 was admitted on August 11, 2023, and was discharged on March 28, 2024. A release of information dated August 11, 2023, to a funding source, did not contain a signature or date.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
the facility failed to obtain a completed informed and voluntary consent which included the dated signature of the client in two out of seven records reviewed.
Client # 1 was admitted on September 19, 2023, and was still active at that the time of the inspection. A release of information dated September 19, 2023, to a single county authority, did not contain a signature or date.
Client #7 was admitted on August 11, 2023, and was discharged on March 28, 2024. A release of information dated August 11, 2023, to a funding source, did not contain a signature or date.
The Facility Director will review with all counselors the proper and complete way to complete all aspects of an appropriate consent including necessity of acquiring all necessary signatures and dates.
The Facility Director, Project Director, and Lead counselor will monitor compliance with these standards through continued supervision and quality review of 3 client files per counselor 1 time per month.
The agency will be in compliance with this standard as of 8/31/24
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709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of the client records, the facility failed to obtain an informed and voluntary consent that recorded the date, event, or condition upon which the consent will expire in one out of seven records reviewed.
Client #1 was admitted on September 19, 2023, and was still active at the time of the inspection. A release of information, dated September 19, 2023, to a government agency, did not document a date or condition for expiration.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
the facility failed to obtain an informed and voluntary consent that recorded the date, event, or condition upon which the consent will expire in one out of seven records reviewed.
Client #1 was admitted on September 19, 2023, and was still active at the time of the inspection. A release of information, dated September 19, 2023, to a government agency, did not document a date or condition for expiration.
The Facility Director will meet with all counselors to review the policies and procedures for correctly completing all aspects of an appropriate consent including the importance of documenting a date or condition for expiration.
The Facility Director, Program Director, and Lead Counselor will monitor compliance with these standards through continued supervision and quality review of 3 client files per counselor 1 time per month.
The agency will be in compliance with this standard as of 8/31/24 |
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 the client records, the facility failed to document that a copy of a client consent shall be offered to the client and a copy maintained in the client record in three out of seven client records reviewed.
Client #2 was admitted on December 14, 2023, and was still active at the time of the inspection. A consent dated December 14, 2023, to a funding source, did not contain documentation of the client's acceptance or refusal of a copy of the consent. Additionally, a consent, dated December 14, 2023, to a government agency, did not contain documentation of the client's accept or refusal of a copy of the consent.
Client #4 was admitted on November 7, 2023, and discharged on February 6, 2024. A consent dated November 7, 2023, to a funding source, did not contain documentation of the client's acceptance or refusal of a copy of the consent. Additionally, a consent, dated November 7, 2023, to a government agency, did not contain documentation of the client's accept or refusal of a copy of the consent.
Client #5 was admitted on August 28, 2023, and discharged on April 16, 2024. A consent dated August 28, 2023, to a government agency, did not contain documentation of the client's accept or refusal of a copy of the consent.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
the facility failed to document that a copy of a client consent shall be offered to the client and a copy maintained in the client record in three out of seven client records reviewed.
Client #2 was admitted on December 14, 2023, and was still active at the time of the inspection. A consent dated December 14, 2023, to a funding source, did not contain documentation of the client's acceptance or refusal of a copy of the consent. Additionally, a consent, dated December 14, 2023, to a government agency, did not contain documentation of the client's accept or refusal of a copy of the consent.
Client #4 was admitted on November 7, 2023, and discharged on February 6, 2024. A consent dated November 7, 2023, to a funding source, did not contain documentation of the client's acceptance or refusal of a copy of the consent. Additionally, a consent, dated November 7, 2023, to a government agency, did not contain documentation of the client's accept or refusal of a copy of the consent.
Client #5 was admitted on August 28, 2023, and discharged on April 16, 2024. A consent dated August 28, 2023, to a government agency, did not contain documentation of the client's accept or refusal of a copy of the consent.
The Facility Director will meet with all counselors to review the policies and procedures for correctly completing all aspects of an appropriate consent including the documentation of the client's acceptance or refusal of a copy of the consent.
The Facility Director, Program Director, and Lead Counselor will monitor compliance with these standards through continued supervision and quality review of 3 random client files per each counselor 1 time per month.
The agency will be in compliance with this standard as of 8/31/24 |
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 a review of unusual incident reports and interviews with facility staff, the facility failed to inform the Department of an unusual incident within the required three business day regulatory time frame. The facility had documentation that an unusual incident occurred on January 4, 2024. This incident involved the presence of the police and an ambulance at the facility. The facility did not submit a written unusual incident report to the Department.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Based on a review of unusual incident reports and interviews with facility staff, the facility failed to inform the Department of an unusual incident within the required three business day regulatory time frame. The facility had documentation that an unusual incident occurred on January 4, 2024. This incident involved the presence of the police and an ambulance at the facility. The facility did not submit a written unusual incident report to the Department.
The Facility Director and Program Director will meet with all staff to review policies and procedures for unusual incident reports including what, why, and when incident reports are to be submitted to the Department.
The Facility Director and Program Director will monitor compliance with these standards during continued supervision.
The agency will be in compliance with this standard as of 8/31/24 |
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 client records, the facility failed to document a comprehensive treatment plan within guidelines established by the facility's policy and procedures manual in four out of seven applicable records reviewed. The facility's policy and procedures manual states the comprehensive treatment plan must be completed within thirty days of intake.
Client #2 was admitted on December 14, 2023, and was still active at the time of the inspection. A comprehensive treatment plan was due no later than January 14, 2024; however, it was not completed until May 30, 2024.
Client #4 was admitted on November 7, 2023, and discharged on February 6, 2024. A comprehensive treatment plan was due no later than December 7, 2023; however, it was not completed until February 6, 2024.
Client #5 was admitted on August 28, 2023, and discharged on April 16, 2024. A comprehensive treatment plan was due no later than September 28, 2023; however, it was not completed until November 21, 2023.
Client #7 was admitted on August 11, 2023, and discharged on March 28, 2024. A comprehensive treatment plan was due no later than September 11, 2023; however, it was not completed until September 29, 2023.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
the facility failed to document a comprehensive treatment plan within guidelines established by the facility's policy and procedures manual in four out of seven applicable records reviewed. The facility's policy and procedures manual states the comprehensive treatment plan must be completed within thirty days of intake.
Client #2 was admitted on December 14, 2023, and was still active at the time of the inspection. A comprehensive treatment plan was due no later than January 14, 2024; however, it was not completed until May 30, 2024.
Client #4 was admitted on November 7, 2023, and discharged on February 6, 2024. A comprehensive treatment plan was due no later than December 7, 2023; however, it was not completed until February 6, 2024.
Client #5 was admitted on August 28, 2023, and discharged on April 16, 2024. A comprehensive treatment plan was due no later than September 28, 2023; however, it was not completed until November 21, 2023.
Client #7 was admitted on August 11, 2023, and discharged on March 28, 2024. A comprehensive treatment plan was due no later than September 11, 2023; however, it was not completed until September 29, 2023.
The Facility Director and Program Director will meet with all counselors to review the policy and procedures for timelines for the completion of comprehensive treatment planning.
The Facility Director, Program Director, and Lead Counselor will monitor compliance with these standards through continued supervision and quality review of client charts.
The agency will be in compliance with this standard as of 8/31/2024 |
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 document treatment plan updates within the regulatory timeframe in two out of five applicable client records.
Client #1 was admitted on September 19, 2023, and was still active at the time of the inspection. A comprehensive treatment plan was completed on October 3, 2023, and the next update was due no later than December 3, 2023; however, the next update was completed on December 5, 2023. The subsequent update was due February 5, 2024; however, the next update was completed February 27, 2024.
Client #6 was admitted on June 12, 2023, and discharged on October 24, 2023. A comprehensive treatment plan was completed on July 1, 2023, and the next update was due no later than September 1, 2023; however, it was completed until September 12, 2023.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
the facility failed to document treatment plan updates within the regulatory timeframe in two out of five applicable client records.
Client #1 was admitted on September 19, 2023, and was still active at the time of the inspection. A comprehensive treatment plan was completed on October 3, 2023, and the next update was due no later than December 3, 2023; however, the next update was completed on December 5, 2023. The subsequent update was due February 5, 2024; however, the next update was completed February 27, 2024.
Client #6 was admitted on June 12, 2023, and discharged on October 24, 2023. A comprehensive treatment plan was completed on July 1, 2023, and the next update was due no later than September 1, 2023; however, it was completed until September 12, 2023.
The Facility Director/Program Director will meet with all counselors to review the policies and procedures for adherence to the timelines for completing treatment plan updates.
The Facility Director, Program Director, and Lead Counselor will monitor compliance with these standards through continued supervision and quality review of 3 random client files per counselor 1 time per month.
The agency will be in compliance with this standard as of 8/31/2024
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