INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 9, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, KARE Services, LLC dba Kolmac Outpatient Recovery 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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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on a review of personnel records, the facility failed to ensure that employee #1, who was hired as the facility director on June 3, 2024 met the minimum qualifications for the position.
There was documentation in the personnel record indicating the employee has a master's degree; however, the employee did not have any program planning experience within a human service agency prior to hiring.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Kolmac will ensure this regulation is met by appointing a new Facility/Program Director who meets all required qualifications for the position. We will document this change on the appropriate forms and submit them to the Department by August 9th, 2024. Their resume documenting their experience and education will be made available for review.
To prevent recurrence of this deficiency, Kolmac will implement a process whereby any candidate for consideration for the role of Project/Facility director will need to be approved by the VP of Compliance and organization leadership. This will include the creation of a checklist of the requirements for the position, against which the candidate's credentials and experience will be reviewed.
The Compliance Manager and VP of Compliance will be responsible for implementing this process. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of the Staffing Requirement Facility Summary Report, the facility failed to ensure the FTE counselor caseload did not exceed 35 active clients.
The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by the facility's workweek. Then, in order to obtain the counselor's caseload ratio, the total number of clients on the counselor's outpatient caseload is divided by the FTE.
Employee #1 was hired as the project director/facility director June 3, 2024 and was the only clinical staff employed at the time of the inspection. The employee's ratio calculation was as follows: 35/40 = .875(FTE); 41/.875= 46.85 which equals a client/counselor ratio of 46:1.
This finding reviewed with facility staff during the licensing process.
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Plan of Correction
Kolmac will ensure this regulation is met by hiring an additional SUD counselor. The current patient caseload will be divided appropriately to maintain the required counselor to patient ratio. Patient census will be monitored each month to determine if additional counselors will be needed to maintain the 35:1 ration.
A new SUD counselor was hired on 7/29/2024 and the caseload is being divided to ensure neither counselor is operating outside of the 35:1 ratio.
The Facility/Project Director and the Compliance Team (Compliance Manager and/or VP of Compliance) will review the census monthly to ensure the 35:1 ratio is maintained. If additional counseling staff is needed, this will be communicated to organization leadership and Talent Acquisition so additional staff can be hired. |
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on a review of the facility's policy and procedure manual, the project director failed to annually update and sign the written manual, which delineates the project ' s policies and procedures.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Kolmac will ensure this regulation is met by developing an annual review schedule and form to use to document the Director's review and acknowledgement of the policies and procedures. Copies of all annual signed acknowledgments will be maintained in the policy and procedure binder.
The Facility/Project Director and Compliance Team will be responsible for implementing this process.
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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 client records, the facility failed to obtain an informed and voluntary consent to release information form prior to the disclosure of information in six of seven client records reviewed.
Client #1 was admitted on October 23, 2023 and was active at the time of inspection. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
Client #2 was admitted on December 4, 2023 and was active at the time of inspection. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
Client #3 was admitted on February 28, 2024 and was active at the time of inspection. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
Client #4 was admitted on November 16, 2023 and was discharged on February 15, 2024. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
Client #6 was admitted on March 6, 2024 and was discharged on May 15, 2024. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
Client #7 was admitted on March 18, 2024 and was discharged on July 1, 2024. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
This is a repeat citation from the August 17, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Kolmac will create a new ROI form specifically for the funding source. The ROI will be reviewed with patients during New Patient Orientation and the Practice Manager will ensure the ROI is completed before the patient will be allowed to begin receiving services.
The Practice Manager will conduct a follow up project to ensure all active clients have the Funding Source ROI on file. The new Funding Source ROI will be available to all patients going forward via the patient portal.
This will be added as an item to our checklist for monthly chart audits so we can monitor and ensure these are being completed. We will review with PA staff the new ROI and ensure they are using the correct form to capture this consent.
The Compliance Team, Project/Facility Director and Practice Manager are responsible for implementing this corrective action.
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709.31 (b) LICENSURE Data collection system
§ 709.31. Data collection system.
(b) The recordkeeping system must allow for the identification of clients' admissions and discharges within a specific time period.
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Observations
Based on an administrative review, the facility failed to maintain a recordkeeping system that allowed for the identification of clients' admission dates and discharge dates within a specific time period.
The facility's recordkeeping system was able to identify clients' admission dates; however, the discharged dates were not able to be identified correctly and accurately.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Kolmac will ensure this regulation is met by collaborating with our IT and EHR teams to create a report we can produce when requested that accurately lists the admission and discharge dates.
The Compliance team and IT team are responsible for the implementation of this corrective action. |
709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on a review of client records, the facility failed to include, during the intake and admission process, documentation of the disclosure, to the client, of the criteria for admission, treatment, completion, and discharge four of seven client records reviewed.
Client #1 was admitted on October 23, 2023 and was active at the time of inspection. There was no documentation the client criteria was disclosed to the client as of the date of the inspection.
Client #2 was admitted on December 4, 2023 and was active at the time of inspection. There was no documentation the client criteria was disclosed to the client as of the date of the inspection.
Client #4 was admitted on November 16, 2023 and was discharged on February 15, 2024. There was no documentation the client criteria was disclosed to the client prior to discharge.
Client #5 was admitted on October 11, 2023 and was discharged on May 6, 2024. There was no documentation the client criteria was disclosed to the client prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Kolmac will ensure this regulation is met by ensuring that all patients receive a copy of the patient handbook and attend New Patient Orientation, which covers this information. Specific language documenting a review of the criteria for admission, treatment, completion and discharge will be added to the Patient Orientation Acknowledgement and signed by all new patients.
This item will be added to our monthly chart review checklist. The PA clinical team will review charts monthly to ensure these requirements have been met.
The Compliance team, Project/Facility Director, and Practice Manager are responsible for implementing this corrective action.
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709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
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Observations
Based on a review of client records, the facility failed to provide client orientation to the project, which is to include a familiarization with project policies, in four of seven client records reviewed.
Client #1 was admitted on October 23, 2023 and was active at the time of inspection. There was no documentation the client was familiarized with project policies as of the date of the inspection.
Client #2 was admitted on December 4, 2023 and was active at the time of inspection. There was no documentation the client was familiarized with project policies as of the date of the inspection.
Client #4 was admitted on November 16, 2023 and was discharged on February 15, 2024. There was no documentation the client was familiarized with project policies prior to discharge.
Client #5 was admitted on October 11, 2023 and was discharged on May 6, 2024. There was no documentation the client was familiarized with project policies prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Kolmac will ensure this regulation is met by ensuring that all patients receive a copy of the patient handbook and attend New Patient Orientation, which covers this information. Specific language documenting a review of the program policies will be added to the Patient Orientation Acknowledgement and signed by all new patients.
This item will be added to our monthly chart review checklist. The PA clinical team will review charts monthly to ensure these requirements have been met.
The Compliance team, Project/Facility Director, and Practice Manager are responsible for implementing this corrective action. |
709.91(b)(2)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(ii) Hours of operation.
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Observations
Based on a review of client records, the facility failed to provide client orientation to the project, which is to include a familiarization with hours of operation, in four of seven client records reviewed.
Client #1 was admitted on October 23, 2023 and was active at the time of inspection. There was no documentation the client was familiarized with the hours of operation as of the date of the inspection.
Client #2 was admitted on December 4, 2023 and was active at the time of inspection. There was no documentation the client was familiarized with the hours of operation as of the date of the inspection.
Client #4 was admitted on November 16, 2023 and was discharged on February 15, 2024. There was no documentation the client was familiarized with the hours of operation prior to discharge.
Client #5 was admitted on October 11, 2023 and was discharged on May 6, 2024. There was no documentation the client was familiarized with the hours of operation prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Kolmac will ensure this regulation is met by ensuring that all patients receive a copy of the patient handbook and attend New Patient Orientation, which covers this information. Specific language documenting a review of the hours of operation will be added to the Patient Orientation Acknowledgement and signed by all new patients.
This item will be added to our monthly chart review checklist. The PA clinical team will review charts monthly to ensure these requirements have been met.
The Compliance team, Project/Facility Director, and Practice Manager are responsible for implementing this corrective action. |
709.91(b)(2)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iii) Fee schedule.
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Observations
Based on a review of client records, the facility failed to provide client orientation to the project, which is to include a familiarization with the fee schedule, in four of seven client records reviewed.
Client #1 was admitted on October 23, 2023 and was active at the time of inspection. There was no documentation the client was familiarized with the fee schedule as of the date of the inspection.
Client #2 was admitted on December 4, 2023 and was active at the time of inspection. There was no documentation the client was familiarized with the fee schedule as of the date of the inspection.
Client #4 was admitted on November 16, 2023 and was discharged on February 15, 2024. There was no documentation the client was familiarized with the fee schedule prior to discharge.
Client #5 was admitted on October 11, 2023 and was discharged on May 6, 2024. There was no documentation the client was familiarized with the fee schedule prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Kolmac will ensure this regulation is met by ensuring that the Patient Engagement Team reviews the financial responsibility with each patient and documents this review in the patient's chart during admission. Specific language documenting a review of the fee schedule will be added to the Patient Orientation Acknowledgement and signed by all new patients.
This item will be added to our monthly chart review checklist. The PA clinical team will review charts monthly to ensure these requirements have been met.
The Compliance team, Director of Admissions, and Practice Manager are responsible for implementing this corrective action.
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709.91(b)(2)(iv) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iv) Services provided.
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Observations
Based on a review of client records, the facility failed to provide client orientation to the project, which is to include a familiarization with the services provided, in four of seven client records reviewed.
Client #1 was admitted on October 23, 2023 and was active at the time of inspection. There was no documentation the client was familiarized with the services provided as of the date of the inspection.
Client #2 was admitted on December 4, 2023 and was active at the time of inspection. There was no documentation the client was familiarized with the services provided as of the date of the inspection.
Client #4 was admitted on November 16, 2023 and was discharged on February 15, 2024. There was no documentation the client was familiarized with the services provided prior to discharge.
Client #5 was admitted on October 11, 2023 and was discharged on May 6, 2024. There was no documentation the client was familiarized with the services provided prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Kolmac will ensure this regulation is met by ensuring that all patients receive a copy of the patient handbook and attend New Patient Orientation, which covers this information. Specific language documenting a review of the services provided will be added to the Patient Orientation Acknowledgement and signed by all new patients.
This item will be added to our monthly chart review checklist. The PA clinical team will review charts monthly to ensure these requirements have been met.
The Compliance team, Project/Facility Director, and Practice Manager are responsible for implementing this corrective action.
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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 ensure individual treatment and rehabilitation plans were developed and documented with the client in three of six applicable client records reviewed.
Client #2 was admitted on December 4, 2023 and was active at the time of inspection. The individual treatment and rehabilitation plan was signed and dated by facility staff on December 19, 2023; however, there was no documentation indicating the plan was developed with the client's input.
Client #3 was admitted on February 28, 2024 and was active at the time of inspection. The individual treatment and rehabilitation plan was signed and dated by facility staff on March 8, 2024; however, there was no documentation indicating the plan was developed with the client's input.
Client #7 was admitted on March 18, 2024 and was discharged on July 1, 2024. There was no individual treatment and rehabilitation plan documented in the 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
Kolmac will ensure this regulation is met by creating a note in the chart confirming the patient participated in the creation of the treatment plan.
Furthermore, Kolmac will add this item to the monthly chart reviews to ensure all patients have an initial treatment plan and documentation that they participated in the development of that plan.
The Compliance team and the Project/Facility Director are responsible for implementing this corrective action.
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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 maintain a complete client record, which is to include follow-up information, in three of three applicable records reviewed.
Client #4 was admitted on November 11, 2023 and was discharged on February 15, 2024. There was no follow-up information documented in the record as of the date of the inspection.
Client #5 was admitted on October 11, 2023 and was discharged on May 6, 2024. There was no follow-up information documented in the record as of the date of the inspection.
Client #6 was admitted on March 6, 2024 and was discharged on May 14, 2024. There was no follow-up information documented in the record as of the date of the inspection.
This is a repeat citation from the September 8, 2021, August 15, 2022, and August 17, 2023 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Kolmac Compliance and Patient Engagement staff will collaborate to revise the procedure for patient follow up. A non-billable note has been created for staff to use to document the follow up for each patient.
Training will be provided to staff on what information to include in follow-up notes and when to complete this documentation. We will conduct monthly chart audits to ensure staff are documenting this appropriately in the chart.
The Compliance team and Director of Admissions are responsible for implementing this corrective action.
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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 completing and documenting follow-up information in the client record were submitted and approved by the Department for the August 17, 2023, August 15, 2022, and September 8, 2021 annual licensing inspections. Not completing and documenting follow-up information was again found to be a deficiency in the July 9, 2024 licensing inspection.
This is a repeat citation from the August 15, 2022 and August 17, 2023 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Administrative Citation Response
Specific plan of correction measures for each of the repeat deficiencies were noted for each item. Below is our plan for how we intend to comply with the plan of correction approved by the Department.
Kolmac will first review all deficiencies identified by the Department with clinical and facility leadership so there is an understanding of the items we need to correct. We will solicit input on how we can best resolve the issues and monitor ourselves to ensure consistency and adherence to the plan of correction and all Department regulations.
Kolmac has appointed a new VP of Compliance and Operations. Increasing the bandwidth in this department will enable our organization to provide greater oversite and monitoring to ensure our plan of correction measures are being implemented and actioned consistently. Kolmac Compliance will meet monthly with the facility and patient engagement teams to review progress towards plan of correction goals. .
For items specifically related to patient chart documentation, we will implement the following actions to ensure we are compliant with our plan of correct and the Department's regulations.
Follow Up Not Documented in Charts
Deficiencies ? Follow-up documentation when patient is discharged was not present in the patient charts.
Kolmac Compliance and Patient Engagement staff will collaborate to revise the procedure for patient follow up. A non-billable note has been created for staff to use to document the follow up for each patient.
Training will be provided to staff on what information to include in follow-up notes and when to complete this documentation. We will conduct monthly chart audits to ensure staff are documenting this appropriately in the chart.
The Compliance team is responsible for implementing these corrective actions. |