INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on November 15, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, St. Luke's Penn Foundation 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:
|
Plan of Correction
|
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
|
Observations
Based on a review of the facility's November 2021 through October 2022 fire drill log, the facility failed to conduct unannounced fire drills at least once a month during the months of November 2021, December 2021, January 2022, March 2022, and April 2022.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
By 12/1/2022, maintenance department will be re-trained on properly conducting fire drills at the outpatient locations. Department supervisor was made aware that verbal drills are not to be conducted and that the persons occupying the building at the time of the unannounced drill will be evacuated. Supervisor will review with the department how to properly fill out the fire drill log form. Practice Administrator at the site will review the completed fire drill form monthly to ensure compliance. |
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.
|
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 three of seven client records reviewed.
The policy and procedure manual stated that the comprehensive treatment plan will be completed within 60 days of admission. Additionally, the manual stated that case consultations will be completed every 3 months.
Client #1 was admitted on February 28, 2022 and was active at the time of inspection. The comprehensive treatment plan was due no later than April 28, 2022; however, the plan was completed by the counselor on September 1, 2022. Additionally, the first case consultation was due no later than May 28, 2022; however, the case consultation was completed on September 1, 2022.
Client #2 was admitted on March 3, 2022 and was active at the time of inspection. The first case consultation was due no later than June 3, 2022; however, the case consultation was completed on July 11, 2022.
Client #6 was admitted on April 8, 2022 and was discharged on October 19, 2022. The comprehensive treatment plan was due no later than June 8, 2022; however, the plan was completed by the counselor on August 24, 2022.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
By 12/15/2022 Clinical supervisor will meet with clinicians in both group and individual supervisions to review policies and procedures regarding the timeline for the completion of treatment plans, updates, and case conferences. Chart audits will occur monthly by the clinical supervisor to ensure compliance. If treatment plans, updates, or case conferences are late disciplinary action may be taken. |
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).
|
Observations
Based on a review of client records, the facility failed to document the dated signature of client on release of information forms in two of seven client records reviewed.
Client #1 was admitted on February 28, 2022 and was active at the time of inspection. There was a release of information form to a probation and parole office that was signed and dated by a witness on March 7, 2022; however, the dated signature of the client was not documented.
Client #4 was admitted on February 11, 2022 and was discharged on September 15, 2022. There was a release of information form to a probation and parole office that was signed and dated by a witness on March 2, 2022; however, the dated signature of the client was not documented.
This is a repeat citation from the September 30, 2020 and October 25, 2021 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
By 12/15/2022, all staff who complete Consent to Release Information forms will be retrained to review requirements for completing release forms. By 12/15/2022, the Accreditation & Standards Coordinator will conduct chart audits in conjunction with the audit committee to monitor compliance and initiate action when non-compliance is identified. By 1/1/2023, adjustments will be made to the electronic health record to require supervisor approval of all Consent to Release Information forms, supervisor will check for client and witness signature, if either signature is missing, supervisor will create a "red x" and notify the staff person to obtain the signature. Once corrected the supervisor will approve the document. Compliance will be monitored via monthly chart audits by the Accreditation & Standards Coordinator and reviewed in the monthly audit committee.
Client #1: The counselor will not disclose information to probation until a consent to release information is signed by the client. Counselor will discuss this with the client at the next scheduled session. |
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.
|
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 four of four applicable client records reviewed.
Client #1 was admitted on February 28, 2022 and was active at the time of inspection. The comprehensive treatment plan was completed on September 1, 2022, and the first update was due no later than November 1, 2022; however, the update was not completed at the time of the inspection.
Client #2 was admitted on March 3, 2022 and was active at the time of inspection. The comprehensive treatment plan was completed on March 31, 2022, and the first update was due no later than May 31, 2022; however, the update was completed on June 20, 2022. Additionally, the next treatment plan update was due no later than August 20, 2022; however, the update was completed on October 5, 2022.
Client #3 was admitted on April 6, 2022 and was active at the time of inspection. The comprehensive treatment plan was completed on May 2, 2022, and the first update was due no later than July 2, 2022; however, the update was completed on July 18, 2022.
Client #4 was admitted on February 11, 2022 and discharged on September 15, 2022. A treatment plan update was completed on June 22, 2022, and the next update was due no later than August 22, 2022; however, the update was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
By 12/15/2022 the clinical supervisor will meet with clinicians in both group and individual supervisions to review policies regarding timeline for the completion of treatment plan reviews. Chart audits will be conducted monthly by the clinical supervisor to ensure compliance. Concerns will be addressed in individual supervision and documented in supervision notes. If treatment plan updates are late disciplinary action may be taken.
Client #1 - treatment plan update was completed on 11/16/2022.
Client #2 - treatment plan update was due and completed on 12/5/2022.
Client #3 - treatment plan updates are up to date.
Client #4 - client is no longer in treatment. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
|
Observations
Based on a review of client records, the facility failed to ensure that counseling services were being provided according to the individual treatment and rehabilitation plan in two of five applicable client records reviewed.
Client #1 was admitted on February 28, 2022 and was active at the time of inspection. The comprehensive treatment plan, dated September 1, 2022, specified one individual counseling session per week. There was no documentation, in the record, of an individual counseling session occurring during the week of October 2, 2022 - October 8, 2022.
Client #2 was admitted on March 3, 2022 and was active at the time of inspection. The treatment plan update, dated June 20, 2022, specified one individual counseling session per week. There was no documentation, in the record, of an individual counseling session occurring during the week of July 31, 2022 - August 6, 2022.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
By 12/15/2022, Clinical supervisors will conduct clinician staff training to ensure client scheduling occurs in accordance with what the treatment plan indicates. If a client is not meeting with the clinician, the clinician will document the reason services have not been provided (client vacation, incarceration, etc.). Treatment plans will be updated if a change in type and frequency of a client's treatment occurs. Clinical supervisors will conduct monthly chart audits to ensure compliance with the regulation. |
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.
|
Observations
Based on a review of client records, the facility failed to document a complete client record, which is to include follow-up information, in four of four applicable client records reviewed.
Client #4 was admitted on February 11, 2022 and was discharged on September 15, 2022. There was follow-up documentation in the record as of the date of the inspection.
Client #5 was admitted on April 25, 2022 and was discharged on September 28, 2022. There was follow-up documentation in the record as of the date of the inspection.
Client #6 was admitted on April 8, 2022 and was discharged on October 19, 2022. There was follow-up documentation in the record as of the date of the inspection.
Client #7 was admitted on May 6, 2022 and was discharged on September 5, 2022. There was follow-up documentation in the record as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
By 12/15/2022 Medical receptionists will be re-trained in completing follow up calls to ensure clients were successfully connected to their aftercare plans. The calls will be conducted within 7 days of discharge. Documentation will be listed in the client record. Clinical supervisors will conduct monthly chart audits to ensure compliance with this regulation |
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.
|
Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for documenting the dated signature of the client on release of information forms were submitted and approved by the Department for the September 30, 2020 and October 25, 2021 annual licensing inspections. Documenting the dated signature of the client on release of information forms were again found to be a deficiency in the November 15, 2022, licensing inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Corrective action will include: By 1/1/2023, adjustments will be made to the electronic health record to require supervisor approval of all Consent to Release Information forms, supervisor will check for client and witness signature, if either signature is missing, supervisor will create a "red x" and notify the staff person to obtain the signature. Once corrected the supervisor will approve the document. Additionally, by 12/15/2022, all staff who complete Consent to Release Information forms will be retrained to review requirements for completing release forms. By 12/15/2022, the Accreditation & Standards Coordinator will conduct chart audits in conjunction with the audit committee to monitor compliance and initiate action when non-compliance is identified. Compliance will be monitored via monthly chart audits by the Accreditation & Standards Coordinator and reviewed in the monthly audit committee |