INITIAL COMMENTS
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This report is a result of an onsite complaint investigation conducted February 27-28, 2024, by staff from the Bureau of Program Licensure. Based on the findings of the onsite complaint investigation, Angel's Light Addiction Specialists was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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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 information provided by a former employee on March 4, 2024, the facility failed to ensure clients confidentiality.
Boxes of paperwork containing client identifying information were given by the facility's owner to a terminated employee on March 1, 2024 and discovered by the former employee on March 4, 2024. The documentation includes client names, birthdates, MRN numbers, social security numbers, drug and alcohol diagnosis and treatment services.
The documentation was returned to facility staff on March 4, 2024.
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Plan of Correction
The staff member who distributed paperwork must attend SUD Confidentiality via the TMS (Keystone) website, to be completed by 3/20/24. Upon completion, the staff member will review the training and provide the certificate of completion to the staff member's direct supervisor. A copy of the training will be placed into the staff member's personnel file. The staff member will also roleplay confidentiality scenarios to ensure that they have grasped the needed content in its needed capacity to treat/work with protected individuals. This staff member was addressed and has received a written disciplinary action plan. |
709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
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Observations
Based on a review of client charts during a complaint investigation conducted on February 27-28, 2024, the facility failed to maintain an efficient recordkeeping system.
Facility staff were unable to located all of the requested client charts during the investigation.
This was discussed with facility staff during the investigation.
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Plan of Correction
Angel's Light Addiction Specialists Project Director will review the policies regarding recordkeeping for client documentation with clinical staff. Our policy for documentation is due within 24 hours. Clinical/Counselors are responsible for upholding and maintaining their assigned client charts. ALAS has implemented immediate accountability for staff regarding missing/late/incomplete paperwork. Employees who fail to update and accurately maintain their active/closed client charts before handing them over to the clinical director to store after discharge in a locked filing cabinet will be held accountable with verbal warnings, written warnings, and timeframes for improvements, if improvements are not made termination is a possibility for the employee who fails to accurately maintain their clinical duties. The Clinical Director will oversee the 24-hour documentation due date as the clinical director works closely with the counselors daily. The Clinical Director will undergo training with ALAS Quality Assurance staff and learn to effectively maintain, store, and locate client files. ALAS is in the process of switching from paper charts to electronic medical records. ALAS is currently waiting for the uploading and correcting of documents within the EMR to ensure compliance. Once compliance is met with the new EMR, client records will immediately be moved to electronic records as admissions enter the facility, the facility will have an electronic chart for more secure storage of client records, along with retrieval of data needed to measure the project's performance in relationship to its stated goals and objectives. |
709.17(a)(5) 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:
(5) Fraud, deceit, misrepresentation or bribery in obtaining or attempting to obtain a license.
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Observations
Based on a review of client charts, administrative documentation, and staff interviews during a complaint investigation conducted on February 27-28, 2024, it was discovered that the facility has been participating in fraudulent practices.
- Group counseling notes are being signed by staff who did not facilitate the groups.
- Clinical client chart documentation is being backdated.
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Plan of Correction
Angel's Light Addiction Specialists Project Director immediately informed clinical staff along with the clinical director that this is not an acceptable form of practice and were informed to immediately cease any fraudulent practices such as backdating/signing of any documentation that they did not do themselves. The Project Director reviewed with the clinical team that ALAS policy will be enforced to hold staff accountable for not completing their required paperwork within the required timeframe per regulations and policies, along with maintaining the client record to ensure all documentation is there for review by any contracted agencies/audits/inspections/complaints, etc. Staff members who fail to complete their documentation within the required timeframe per regulation and policy will receive disciplinary action. The Project Director also reviewed with the Clinical Director that DDAP does not have a capacity for group therapy, and ALAS contracted agencies limit the number of individuals in outpatient therapy settings, not 3.5 LOC. |