INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 17-18, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, BioCare Recovery Centers 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
During a licensing inspection conducted on September 17- 18, 2019, the facility failed to ensure that Employee # 3 received the minimum of 6 hours of HIV/AIDS training within the regulatory timeframe.
Employee # 3 was hired as a counselor on May 7, 2018 and was due to have the communicable disease trainings no later than May 7, 2019. There was no documentation in the personnel file of the completion of the HIV/AIDS training as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Office Manager will perform audit of all current staff members to identify current trainings and any deficits. All supervisors will include training sheets in annual reviews to ensure training needs are being met. Training sheets will be kept in supervision binders for each staff member. Any new staff will receive training plan as part of their onboarding. |
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
During a licensing inspection conducted on September 17-18, 2019, the facility failed to ensure that there was appropriate documentation of written acknowledgment by the client that the client had been made aware of their rights in client record # ' s 1, 2, 3, 4, 5, 6, and 7 to include:
(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.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Clinical director will update policy and procedure to include clients' right to inspect their records, the process the client will follow to view records, the client right to appeal, client right to request corrections and right to submit rebuttal. Correction will include update to policy and procedure manual, updates to intake paper work and update to client handbook.
Each staff member will be trained in the updated policy and procedure by the clinical director. This will be included in their supervision notes. Quarterly chart audits will check to ensure policy is being followed. Clinical Director and Office manager will be responsible for the corrective action. |
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
During a licensing inspection conducted on September 17-18, 2019, the facility failed to include documentation in their Policies and Procedures on client rights to include:
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.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will update policy and procedure to include Clients' right to inspect their records. Policy to include 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. Additionally, Clients will be informed in writing of this right at intake and will be provided a copy of the policy and will sign in acknowledgement that they were informed. Clinical director, facility director and all clinical staff will be able to review this policy with clients at any time they request. Policy will include records request that will be submitted to clinical director if individuals wishes to review their records. |
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
During a licensing inspection conducted on September 17-18, 2019, the facility failed to include documentation in their Policies and Procedures on client rights to include:
Clients have the right to appeal a decision limiting access to their records to the director.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will update policy and procedure to include Clients' right to inspect their records. Policy to include 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. Additionally, Clients will be informed in writing of this right at intake and will be provided a copy of the policy and will sign in acknowledgement that they were informed. Clients will be informed as part of this policy of their right to appeal the decision to limit access to their records and the process to appeal will be included in the policy.
Clinical director, facility director and all clinical staff will be able to review this policy with clients at any time they request. Policy will include records request that will be submitted to clinical director if individuals wishes to review their records. |
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
During a licensing inspection conducted on September 17-18, 2019, the facility failed to include documentation in their Policies and Procedures on client rights to include:
Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will update policy and procedure to include Clients' right to inspect their records. Policy to include 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. Additionally, Clients will be informed in writing of this right at intake and will be provided a copy of the policy and will sign in acknowledgement that they were informed. Clients will be informed as part of this policy of their right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records. The steps to take to request correction will be included in policy.
Clinical director, facility director and all clinical staff will be able to review this policy with clients at any time they request. |
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
During a licensing inspection conducted on September 17-18, 2019, the facility failed to include documentation in their Policies and Procedures on client rights to include:
Clients have the right to submit rebuttal data or memoranda to their own records.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will update policy and procedure to include Clients' right to inspect their records. Policy to include 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. Additionally, Clients will be informed in writing of this right at intake and will be provided a copy of the policy and will sign in acknowledgement that they were informed. Clients will be informed as part of this policy of their right to submit rebuttal data or memoranda to their own records. Policy to include steps to submit a rebuttal.
Clinical director, facility director and all clinical staff will be able to review this policy with clients at any time they request. Policy will include records request that will be submitted to clinical director if individuals wishes to review their records. |
709.93(a) 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:
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Observations
During a licensing inspection conducted on September 17-18, 2019, the project failed to provide documentation of a complete client record to include a referral source and follow-up information in client record's # 1, 2, 3, 4, 5, 6, and 7.
Client # 1 was admitted on May 14, 2019 and was still an active client at the time of the inspection. The client record did not contain documentation of a referral source.
Client # 2 was admitted on April 10, 2019 and was still an active client at the time of the inspection. The client record did not contain documentation of a referral source.
Client # 3 was admitted on May 6, 2019 and was still an active client at the time of the inspection. The client record did not contain documentation of a referral source.
Client # 4 was admitted on February 18, 2019 and was still an active client at the time of the inspection. The client record did not contain documentation of a referral source.
Client # 5 was admitted on October 2, 2017 and discharged on May 20, 2019. The client record did not contain documentation of follow-up information.
Client # 6 was admitted on October 22, 2018 and was discharged on January 18, 2019. The client record did not contain documentation of a referral contact or follow-up information being conducted within one week of discharge as the project ' s policy and procedure indicates. Follow-up was completed on February 14, 2019.
Client # 7 was admitted on November 16, 2018 and discharged June 14, 2019. The client record did not contain documentation of follow-up information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of August 15th, 2019, Referral source information is collected at the time of intake call, again at evaluation and intake appointment, a release of information is signed for the referral source at the time of the intake and the referral source information is found through the client chart and is tracked in referral source database.
Clinical director is responsible for updating the procedure and ensuring the corrective action is implemented. |