INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 7, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, ADAPPT Outpatient Treatment Services 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of personnel records, the facility failed to ensure that clinical supervisors and lead counselors, who had not functioned for 2 years as a supervisor in the provision of clinical services, completed a Department-approved core curriculum in clinical supervision in one of one applicable personnel record reviewed.
Employee #3 was promoted to lead counselor on February 22, 2021. There was no documentation of clinical supervision experience prior to being hired and no documentation that the clinical supervision core curriculum training was completed as of the date of the inspection.
This is a repeat citation from the February 17, 2022 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will identify and available Clinical Supervision training. The Project Director will oversee the Lead Counselor enrollment in the training. Staff personnel files will be updated to ensure the training is documented. The enrollment will occur on or before 3/3/23. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on review of client records and the policy and procedure manual, the facility failed to follow the project's written procedures for the management of treatment/rehabilitation services in seven of eight client records reviewed.
The facility policy and procedure manual stated that the initial treatment plan will be completed on the day of admission. Additionally, the facility policy and procedure manual stated that the comprehensive treatment plan will be completed within 30 days of service. Also, the facility policy and procedure manual stated that the histories will be completed within 3 days following admission and the psycho-social evaluation will be completed within 30 days of the beginning of treatment.
Client #1 was admitted on April 19, 2022 and was active at the time of inspection. The initial treatment plan was due no later April 20, 2022; however, plan was completed on May 16, 2022. Additionally, the biopsychosocial evaluation was due no later than May 19, 2022; however, the evaluation was completed on May 31, 2022. Also, the comprehensive treatment plan was due no later than May 19, 2022; however, the plan was completed on June 14, 2022.
Client #2 was admitted on July 13, 2022 and was active at the time of inspection. The initial treatment plan was due no later July 14, 2022; however, the plan was completed on September 14, 2022. Additionally, the biopsychosocial evaluation was due no later than August 13, 2022; however, the evaluation was completed on September 21, 2022. Also, the comprehensive treatment plan was due no later than August 13, 2022; however, the plan was completed on October 25, 2022.
Client #3 was admitted on September 14, 2022 and was active at the time of inspection. The initial treatment plan was due no later than September 15, 2022; however, the plan was completed on October 6, 2022. Additionally, the comprehensive treatment plan was due no later than October 14, 2022; however, the plan was completed on October 20, 2022.
Client #4 was admitted on September 14, 2022 and was active at the time of inspection. The comprehensive treatment plan was due no later than October 14, 2022; however, the plan was completed on December 2, 2022.
Client #5 was admitted on May 12, 2022 and was discharged on November 9, 2022. The biopsychosocial evaluation was due no later than June 12, 2022; however, the evaluation was completed on June 15, 2022. Additionally, the comprehensive treatment plan was due no later than June 12, 2022; however, the plan was completed on June 15, 2022.
Client #7 was admitted on May 12, 2022 and November 22, 2022. The comprehensive treatment plan was due no later than June 12, 2022; however, the plan was completed on June 27, 2022.
Client #8 was admitted on May 18, 2022 and November 1, 2022. The comprehensive treatment plan was due no later than June 18, 2022; however, the plan was completed on June 23, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility policy and procedure manual related to the initial treatment plan being completed on the day of admission, the comprehensive treatment plan being completed within 30 days of service, histories being completed within 3 days following admission, and the psycho-social evaluation being completed within 30 days of the beginning of treatment will be trained with all staff by the Project Director. The Facility Director and, or the Lead Counselor will review active files for compliance. Training will occur before 3/3/23. |
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 document the dated signature of the client on release of information forms in two of eight client records reviewed.
Client #1 was admitted on April 19, 2022 and was active at the time of inspection. There were release of information forms to probation and parole, two government agencies, and an emergency contact that were all signed and dated by the witness on April 20, 2022; however, the dated signature of the client was not documented on any of the release forms.
Client #6 was admitted on April 5, 2022 and was discharged on October 27, 2022. There were release of information forms to three government agencies and an emergency contact that were all signed and dated by the witness on April 6, 2022; however, the dated signature of the client was not documented on any of the release forms.
This is a repeat citation from the February 17, 2022 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will train staff on securing signatures on the release of information form. The Facility Director and, or the Lead Counselor will review active files monthly for compliance. Training will occur before 3/3/23. |
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 ensure that a copy of a client consent was offered to the client in two of eight client records reviewed.
Client #5 was admitted on May 12, 2022 and was discharged on November 9, 2022. There were release of information forms to an external treatment program and a government agency that were signed and dated by the client on May 11, 2022; however, there was no documentation that a copy of the either release forms was offered to the client.
Client #8 was admitted on May 18, 2022 and was discharged on November 1, 2022. There were release of information forms to an external treatment program, two government agencies, and an emergency contact that were all signed and dated by the client on May 18, 2022; however, there was no documentation that a copy of any of the release forms were offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will train staff on securing signatures verifying and document that a copy of a client consent was offered to the client. The Facility Director and, or the Lead Counselor will review active files monthly for compliance. Training will occur before 3/3/23. |
709.30 (1) 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.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on a review of client records, the facility failed to include documentation verifying the written acknowledgement by clients that they had been informed of their right to retain civil rights and liberties except as provided by statute in six of eight client records reviewed.
Client #2 was admitted on July 13, 2022 and was active at the time of inspection. There was no documentation that the client acknowledged this client right in the client record at the time of the inspection.
Client #3 was admitted September 14, 2022 and was active at the time of inspection. There was no documentation that the client acknowledged this client right in the client record at the time of the inspection.
Client #4 was admitted September 14, 2022 and was active at the time of inspection. There was no documentation that the client acknowledged this client right in the client record at the time of the inspection.
Client #5 was admitted May 12, 2022 and was discharged on November 9, 2022. There was no documentation that the client acknowledged this client right in the client record at the time of the inspection.
Client #7 was admitted May 12, 2022 and was discharged on November 22, 2022. There was no documentation that the client acknowledged this client right in the client record at the time of the inspection.
Client #8 was admitted May 18, 2022 and was discharged on November 1, 2022. There was no documentation that the client acknowledged this client right in the client record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will train staff on review and documentation verifying the written acknowledgement by the client that they were informed of their right to retain civil rights and liberties, except as provided by statute. The Facility Director and, or the Lead Counselor will review active files monthly for compliance. Training will occur before 3/3/23. |
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 include documentation verifying the written acknowledgement by clients that they had been informed of their right to inspect their own records; 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 the reasons for removing sections shall be documented in the record in six of eight client records reviewed.
Client #2 was admitted on July 13, 2022 and was active at the time of inspection. There was no documentation that the client acknowledged this client right in the client record at the time of the inspection.
Client #3 was admitted September 14, 2022 and was active at the time of inspection. There was no documentation that the client acknowledged this client right in the client record at the time of the inspection.
Client #4 was admitted September 14, 2022 and was active at the time of inspection. There was no documentation that the client acknowledged this client right in the client record at the time of the inspection.
Client #5 was admitted May 12, 2022 and was discharged on November 9, 2022. There was no documentation that the client acknowledged this client right in the client record at the time of the inspection.
Client #7 was admitted May 12, 2022 and was discharged on November 22, 2022. There was no documentation that the client acknowledged this client right in the client record at the time of the inspection.
Client #8 was admitted May 18, 2022 and was discharged on November 1, 2022. There was no documentation that the client acknowledged this client right in the client record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will train staff on review and documentation verifying the written acknowledgement by the client that they were informed of their right to inspect their own records; 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. The Facility Director and, or the Lead Counselor will review active files monthly for compliance. Training will occur before 3/3/23. |
709.30 (4) 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.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on a review of client records, the facility failed to include documentation verifying the written acknowledgement by clients that they had been informed of their right to appeal a decision limiting access to their records to the director in six of eight client records reviewed.
Client #2 was admitted on July 13, 2022 and was active at the time of inspection. There was no documentation that the client acknowledged this client right in the client record at the time of the inspection.
Client #3 was admitted September 14, 2022 and was active at the time of inspection. There was no documentation that the client acknowledged this client right in the client record at the time of the inspection.
Client #4 was admitted September 14, 2022 and was active at the time of inspection. There was no documentation that the client acknowledged this client right in the client record at the time of the inspection.
Client #5 was admitted May 12, 2022 and was discharged on November 9, 2022. There was no documentation that the client acknowledged this client right in the client record at the time of the inspection.
Client #7 was admitted May 12, 2022 and was discharged on November 22, 2022. There was no documentation that the client acknowledged this client right in the client record at the time of the inspection.
Client #8 was admitted May 18, 2022 and was discharged on November 1, 2022. There was no documentation that the client acknowledged this client right in the client record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will train staff on review and documentation verifying the written acknowledgement by the client that they were informed of their right to appeal a decision limiting access to their records to the Director. The Facility Director and, or the Lead Counselor will review active files monthly for compliance. Training will occur before 3/3/23. |
709.30 (5) 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.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Based on a review of client records, the facility failed to include documentation verifying the written acknowledgement by clients that they had been informed of their right to request the correction of inaccurate, irrelevant, outdated, or incomplete information in their records in six of eight client records reviewed.
Client #2 was admitted on July 13, 2022 and was active at the time of inspection. There was no documentation that the client acknowledged this client right in the client record at the time of the inspection.
Client #3 was admitted September 14, 2022 and was active at the time of inspection. There was no documentation that the client acknowledged this client right in the client record at the time of the inspection.
Client #4 was admitted September 14, 2022 and was active at the time of inspection. There was no documentation that the client acknowledged this client right in the client record at the time of the inspection.
Client #5 was admitted May 12, 2022 and was discharged on November 9, 2022. There was no documentation that the client acknowledged this client right in the client record at the time of the inspection.
Client #7 was admitted May 12, 2022 and was discharged on November 22, 2022. There was no documentation that the client acknowledged this client right in the client record at the time of the inspection.
Client #8 was admitted May 18, 2022 and was discharged on November 1, 2022. There was no documentation that the client acknowledged this client right in the client record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will train staff on review and documentation verifying the written acknowledgement by the client that they were informed of their right to request the correction of inaccurate, irrelevant, outdated, or incomplete information in their records. The Facility Director and, or the Lead Counselor will review active files monthly for compliance. Training will occur before 3/3/23. |
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 include documentation verifying the written acknowledgement by clients that they had been informed of their right to submit rebuttal data or memoranda to their own records in six of eight client records reviewed.
Client #2 was admitted on July 13, 2022 and was active at the time of inspection. There was no documentation that the client acknowledged this client right in the client record at the time of the inspection.
Client #3 was admitted September 14, 2022 and was active at the time of inspection. There was no documentation that the client acknowledged this client right in the client record at the time of the inspection.
Client #4 was admitted September 14, 2022 and was active at the time of inspection. There was no documentation that the client acknowledged this client right in the client record at the time of the inspection.
Client #5 was admitted May 12, 2022 and was discharged on November 9, 2022. There was no documentation that the client acknowledged this client right in the client record at the time of the inspection.
Client #7 was admitted May 12, 2022 and was discharged on November 22, 2022. There was no documentation that the client acknowledged this client right in the client record at the time of the inspection.
Client #8 was admitted May 18, 2022 and was discharged on November 1, 2022. There was no documentation that the client acknowledged this client right in the client record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will train staff on review and documentation verifying the written acknowledgement by the client that they were informed of their right to submit rebuttal data or memoranda to their own records. The Facility Director and, or the Lead Counselor will review active files monthly for compliance. Training will occur before 3/3/23. |
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 develop the individual's treatment and rehabilitation plan with the client in three of eight client records reviewed.
Client #1 was admitted on April 19, 2022 and was active at the time of inspection. The comprehensive treatment plan was signed and dated by facility staff on June 14, 2022; however, there was no written documentation that the plan was developed with the client's input.
Client #7 was admitted on May 12, 2022 and was discharged on November 22, 2022. The comprehensive treatment plan was signed and dated by facility staff on June 27, 2022; however, there was no written documentation that the plan was developed with the client's input.
Client #8 was admitted on May 18, 2022 and was discharged on November 1, 2022. The comprehensive treatment plan was signed and dated by facility staff on June 23, 2022; however, there was no written documentation that the plan was developed with the client's input.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will train and ensure staff are aware of requirements related to development of an individual treatment plan and rehabilitation plan and governing timeliness of development. The Facility Director and, or the Lead Counselor will review active files monthly for compliance. Training will occur before 3/3/23. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document the proposed type of support services on the client's individual treatment and rehabilitation plan in five of eight client records reviewed.
Client #1 was admitted on April 19, 2022 and was active at time of inspection. The comprehensive treatment plan was completed on June 14, 2022; however, the plan did not include proposed types of support service.
Client #5 was admitted on May 12, 2022 and was discharged on November 9, 2022. The comprehensive treatment plan was completed on June 15, 2022; however, the plan did not include proposed types of support service.
Client #6 was admitted on April 5, 2022 and was discharged on October 27, 2022. The comprehensive treatment plan was completed on May 3, 2022; however, the plan did not include proposed types of support service.
Client #7 was admitted on May 12, 2022 and was discharged on November 22, 2022. The comprehensive treatment plan was completed on June 27, 2022; however, the plan did not include proposed types of support service.
Client #8 was admitted on May 18, 2022 and was discharged on November 1, 2022. The comprehensive treatment plan was completed on June 23, 2022; however, the plan did not include proposed types of support service.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director added proposed types of support services to the individual treatment and rehabilitation document. The Project Director will train and ensure staff are aware of requirements related to including proposed types of support services in the individual treatment and rehabilitation plan. The Facility Director and, or the Lead Counselor will review active files monthly for compliance. Training will occur before 3/3/23. |
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 a maintain a complete client record on an individual, which is to include case consultation notes, in eight of eight client records reviewed.
Every record reviewed did not have documentation of case consultation notes at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will train and ensure staff are aware of requirements related case consultation notes. The Facility Director and, or the Lead Counselor will review active files monthly for compliance. Training will occur before 3/3/23. |
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 client records, the facility failed to a maintain a complete client record on an individual, which is to include an aftercare plan, in three of four applicable client records reviewed.
Client #6 was admitted on April 5, 2022 and was discharged on October 27, 2022. There was no documentation of an aftercare plan in the record as of the date of the inspection.
Client #7 was admitted on May 12, 2022 and was discharged on November 22, 2022. There was no documentation of an aftercare plan in the record as of the date of the inspection.
Client #8 was admitted on May 18, 2022 and was discharged on November 1, 2022. There was no documentation of an aftercare plan in the record as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will provide counselors with an Aftercare Plan document and will train and ensure staff are aware of requirements related to the inclusion of an Aftercare Plan upon program completion. The Facility Director and, or the Lead Counselor will review discharge files monthly for compliance. Training will occur before 3/3/23. |
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 client records, the facility failed to a maintain a complete client record on an individual, which is to include follow-up information, in three of four applicable client records reviewed.
Client #5 was admitted on May 12, 2022 and was discharged on November 9, 2022. There was no documentation of follow-up information in the record as of the date of the inspection.
Client #6 was admitted on April 5, 2022 and was discharged on October 27, 2022. There was no documentation of follow-up information in the record as of the date of the inspection.
Client #8 was admitted on May 18, 2022 and was discharged on November 1, 2022. There was no documentation of follow-up information in the record as of the date of the inspection.
This is a repeat citation from the February 17, 2022, February 25, 2021, February 13, 2020, January 14, 2019, May 8, 2018, and February 22, 2017 annual licensing inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will provide counselors with a follow-up document and will train and ensure staff are aware of requirements related to client follow-up upon program completion. The Facility Director and, or the Lead Counselor will review discharge files monthly for compliance. Training will occur before 3/3/23. |
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.
Plans of correction for follow-up information were submitted and approved by the Department for the February 17, 2022, February 25, 2021, February 13, 2020, January 14, 2019, May 8, 2018, and February 22, 2017 annual licensing inspections. Follow-up information was again found to be a deficiency in the February 7, 2023 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Due to several contributing factors, several of our corrective actions were not fully adhered to. However in most circumstances, this occurred in some selected files and not all, which requires additional training, quality assurance, and in some instances review of internal policy. With these proposed POC further continuous quality improvement will occur. |