INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 3, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, PA Treatment & Healing 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(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of the facility's staff development program, the facility failed to develop a comprehensive staff development program for the current training year, July 1, 2022 through June 31, 2023.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The project director established new training Policies and procedures. Those procedures were implemented July 1 2022. On page 26-29 of the addiction's treatment manual the training requirements and Training plan for the D&A programs are clearly outlined. It is the responsibility of the Project director to evaluate the previous training plan and establish the new year's Development and training plan for the D&A programs at the end of the previous fiscal year. It is the responsibility of the project director to distribute to all Facility directors the new Training plan annually. |
704.11(a)(4) LICENSURE Evaluation of Overall Plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a review of the facility's staff development program, the facility failed to complete an annual evaluation of the overall training plan for training year July 1, 2021 through June 31, 2022.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The project director established new training Policies and procedures. Those procedures were implemented July 1 2022. On page 26-29 of the addiction's treatment manual the training requirements and Training plan for the D&A programs are clearly outlined. It is the responsibility of the Project director to evaluate the previous training plan and establish the new year's Development and training plan for the D&A programs at the end of the previous fiscal year. It is the responsibility of the project director to distribute to all Facility directors the new Training plan annually. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that staff were instructed in the use of fire extinguishers upon employment.
Employee #2 was hired on April 27, 2022 as the Facility Director and was still in the position as of the date of the inspection. The training was completed on May 25, 2022.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The project director established emergency Policies and procedures. Those procedures were implemented July 1 2022. It is the responsibility of the Project Director and the Facility director to Instruct all agency staff upon hire and bi-annually of the Policies and procedures concerning emergency and Fire emergency protocols. The corrective action plan was reviewed with Agency staff and implemented on 8/5/2022 |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
Employee #2 was hired on April 27, 2022 as the Facility Director and was still in the position as of the date of the inspection. The training was completed on May 25, 2022.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The project director established emergency Policies and procedures. Those procedures were implemented July 1 2022. It is the responsibility of the Project Director and the Facility director to Instruct all agency staff upon hire and bi-annually of the Policies and procedures concerning emergency and Fire emergency protocols.The corrective action plan was reviewed with Agency staff and implemented on 8/5/2022 |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a review of administrative documents and an interview with theProject Director, the project failed to document an annual financial audit for the fiscal year ending June 30, 2021.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
PA Treatment & healing has implemented the following corrective actions in order to comply with the
fiscal management requirement:
Contracted with an independent accounting firm specializing in nonprofits.
Contracted with an independent IT consultant to recover as much data as possible that was lost
due to our accounting server crashing and flooding in our corporate office.
Restructured the accounting department by hiring more staff for proper distribution of workflow.
Establishing new fiscal policies and procedures to ensure a proper system of checks and balances is in place.
These steps are being monitored by President, and Director of Finance,
Our timeline for completion is December 31 2022.
IRS determines the exact date for the actual audit date.
The corrective action plan was reviewed with Agency staff and implemented on 8/5/2022
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709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to obtain a completed informed and voluntary consent which included specific information to be disclosed in one out of five applicable client records.
Client #5 was admitted on January 28, 2022 and was discharged on March 9, 2022. There were release of information forms signed and dated on January 28, 2022 to two medical providers.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The project director established confidentiality Policies and procedures. Proper completion of releases including but not limited to "Specific information disclosed." Those procedures were implemented July 1 2022.
Client #5 was discharged before the new policies and procedures took effect and could not be corrected. It is the responsibility of agency staff to ensure that all releases applicable to the client treatment are signed and completed upon admission. The facility Director will review the admission file to ensure that the entire admit packet is properly completed. In the case of missing information, the Facility director will notify the clinician of the omission and will be required to correct it on the next client visit.
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709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document a completed consent to release form in one out of five applicable client records that had a release of information that was missing the purpose of disclosure.
Client #5 was admitted on January 28, 2022 and was discharged on March 9, 2022. There was a release of information form signed and dated on January 28, 2022 to a medical provider.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The project director established confidentiality Policies and procedures. Proper completion of releases including but not limited to "Purpose of disclosure"
Those procedures were implemented July 1 2022
Client #5 was discharged before the new policies and procedures took effect and could not be corrected. It is the responsibility of agency staff to ensure that all releases applicable to the client treatment are signed and completed upon admission. The facility Director will review the admission file to ensure that the entire admit packet is properly completed. In the case of missing information, the Facility director will notify the clinician of the omission and will be required to correct it on the next client visit.
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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 obtain a completed informed and voluntary consent which included the dated signature of client in two out of five applicable records reviewed.
Client # 3 was admitted on October 22, 2021 and was still active at that the time of the inspection. One release of information dated October 22, 2021 was to a funding source. An additional release of information dated October 22, 2021 was to government agency.
Client #6 was admitted on December 17, 2021 and discharged on July 7, 2022. A release of information dated December 17, 2021 was to a medical provider.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project director established confidentiality Policies and procedures. Proper completion of releases including but not limited to "Dated signature of client or guardian" Those procedures were implemented July 1 2022
It is the responsibility of agency staff to ensure that all releases applicable to the client treatment are signed and completed upon admission. The facility Director will review the admission file to ensure that the entire admit packet is properly completed. In the case of missing information, the Facility director will notify the clinician of the omission and will be required to correct it on the next client visit.
Client #3 will complete a new release for the missing signature in their next visit .
Client #6 Was discharged and therefore can not be corrected.
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709.28 (c) (5) 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:
(5) Dated signature of witness.
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Observations
Based on a review of client records, the facility failed to obtain a completed informed and voluntary consent which included the dated signature of a witness in one out of five applicable records reviewed.
Client # 3 was admitted on October 22, 2021 and was still active at that the time of the inspection. Three releases of information dated October 22, 2021 were to a funding source, government agency and family member.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The project director established confidentiality Policies and procedures. Proper completion of releases including but not limited to "Dated signature of witness." Those procedures were implemented July 1 2022.
It is the responsibility of agency staff to ensure that all releases applicable to the client treatment are signed and completed upon admission. The facility Director will review the admission file to ensure that the entire admit packet is properly completed. In the case of missing information, the Facility director will notify the clinician of the omission and will be required to correct it on the next client visit.
Client #3 will complete a new release for the missing signature in their next visit .
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709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of the client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the clients that recorded the date, event, or condition upon which the consent will expire in five out of five applicable records reviewed.
Client #1 was admitted on March 15, 2022 and was still active at the time of the inspection. Releases of information dated March 15, 2022 were to a funding source, government agency, and two medical providers.
Client # 3 was admitted on October 22, 2021 and was still active at that the time of the inspection. Releases of information dated October 22, 2021 were to a funding source, and government agency.
Client #4 was admitted on January 10, 2022 and was still active at the time of the inspection. Releases of information dated January 10, 2022 were to two government agencies, two medical providers and a funding source.
Client #5 was admitted on January 28, 2022 and discharged on July 7, 2022. Releases of information dated January 28, 2022 were to three medical providers, a funding source and a government agency.
Client #6 was admitted on December 17, 2021 and was discharged on July 7, 2022. Releases of information dated December 17, 2021 were to a funding source, government agency and medical provider.
These finding were reviewed with the facility staff during the licensing process.
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Plan of Correction
The project director established confidentiality Policies and procedures. Proper completion of releases including but not limited to "Date, event or condition upon which the consent will expire." Those procedures were implemented July 1 2022.
It is the responsibility of agency staff to ensure that all releases applicable to the client treatment are signed and completed upon admission. The facility Director will review the admission file to ensure that the entire admit packet is properly completed. In the case of missing information, the Facility director will notify the clinician of the omission.
The corrective action plan was reviewed with Agency staff and implemented on 8/5/2022
Client file was corrected on 8/15/2022.
It is the responsibility of the Facility director to train staff on proper procedures.
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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 the client records, the facility failed to document that a copy of a client consent shall be offered to the client and a copy maintained in the client record in one out of five applicable client records reviewed.
Client #4 was admitted on January 10, 2022 and was still active at the time of the inspection. Releases of information dated January 10, 2022 were to a funding source and government agency.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The project director established confidentiality Policies and procedures. Proper completion of releases including but not limited to "A copy of a client consent shall be offered to the client and a copy maintained in the client record." Those procedures were implemented July 1 2022.
It is the responsibility of agency staff to ensure the client be offered a copy of all applicable paperwork. and is documented on Page I-18 "receipt of Information" The facility Director will review the admission file to ensure that the entire admit packet is properly completed.
The corrective action plan was reviewed with Agency staff and implemented on 8/5/2022
In the case of missing information, the Facility director will notify the clinician of the omission and will be required to correct it on the next client visit on 9/20/22.
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709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Based on a review of client records, the facility failed to inform the Department of unusual incidents within the required three days. It was discovered that the facility had an unusual incident occur on January 24, 2022, February 7, 2022, February 21, 2022, June 2, 2022 and June 7, 2022 all which involved death of a client. Upon further inspection, it was discovered that the facility had not submitted a written unusual incident report to the Department within the regulatory three business day timeframe.
This finding was reviewed with project and facility staff during the licensing process.
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Plan of Correction
Plan of Correction: The project director established unusual incident reporting Pg 35 in the Addictions Policies and procedures. Proper completion of releases including but not limited to "To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving: (2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances." Those procedures were implemented July 1 2022.
The events observed took place before the new implementation of the new procedures.
Pg. 35 "It is the responsibility of the staff member present at the time of the unusual incident to complete the Unusual Incident Report Form. It is the responsibility of the Facility Director for the review and reporting of an unusual incident and forward to the Project director. Generation of follow-up and timely corrective action plan, when needed, will be the responsibility of the Facility Director and Project Director."
The corrective action plan was reviewed with Agency staff and implemented on 8/5/2022 |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to document a complete psychosocial evaluation in three out of five applicable records.
Client #4 was admitted on January 10, 2022 and was still active at the time of the inspection.
Client #5 was admitted on January 28, 2022 and was discharged on March 9, 2022.
Client #6 was admitted on December 17, 2021 and was discharged on July 7, 2022.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The project director established Intake Policies and procedures. Proper completion of required intake paperwork including but not limited to "Intake and admission. (b) Intake procedures shall include documentation of: (6) Psychosocial evaluation. Those procedures were implemented July 1 2022.
Client #4 will have on their next scheduled visit an updated Psychosocial evaluation. It is the responsibility for the Facility director to make sure of compliance.
Client #5 & #6 were discharged and therefore could not be updated. The corrective action plan was reviewed with Agency staff and implemented on 8/5/2022 |
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 document a comprehensive treatment plan with the client within guidelines established by the facility's policy and procedures manual in three out of five applicable records reviewed. The facility's policy and procedures manual states the comprehensive treatment plan must be completed between within 30 days following admission.
Client #4 was admitted on January 10, 2022 and was still active at the time of the inspection. A comprehensive treatment plan was completed on March 4, 2022; however the client did not partcipate in the development of the plan.
Client #5 was admitted on January 28, 2022 and was discharged March 9, 2022. A comprehensive treatment plan was due no later than February 28, 2022; however, there was no documentation of it being completed at the time of the inspection.
Client #6 was admitted on December 17, 2021 and discharged July 7, 2022. A comprehensive treatment plan was due no later than January 17, 2022; however, there was no documentation of it being completed at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The project director established Master Treatment Planning Policies and procedures. Proper completion of required intake paperwork including but not limited to "The facility's policy and procedures manual states the comprehensive treatment plan must be completed between within 30 days following admission." Those procedures were implemented July 1 2022.
It is the responsibility of the clinician to assure that the comprehensive treatment plan is completed with the client prior to 30 days from admission. It is furthermore the responsibility of the facility director to audit the client charts to assure that this policy is adhered to .
Client #4 will have their master treatment plan reviewed with them on their next scheduled appointment .The clinician will document that the review took place.
Client #5 were discharged and therefor could not be corrected . The facility director will retrain all staff on the proper Policies and Procedures concerning client charting . The corrective action plan was reviewed with Agency staff and implemented on 8/5/2022
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709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of the client records, the facility failed to ensure that an individual treatment and rehabilitation plan shall be developed with the client. This plan shall include but not limited to, written documentation of type and frequency of treatment and rehabilitation services in four out of five client records reviewed.
Client #2 was admitted on April 27, 2022 and was still active at the time of the inspection. Treatment plans were developed on November 11, 2021, January 4, 2022 and March 8, 2022.
Client #3 was admitted on October 22, 2021 and was still active at the time of the inspection. Treatment plans were developed on January 12, 2022 and March 17, 2022.
Client #4 was admitted on January 10, 2022 and was still active at the time of the inspection. A treatment plan was developed on June 9, 2022.
Client #7 was admitted on October 8, 2018 and discharged on June 2, 2022. Treatment plans were developed on September 2, 2021, January 14, 2022 and March 28, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project director established Master Treatment Planning Policies and procedures. Proper completion of required intake paperwork including but not limited to "Type and frequency of treatment and rehabilitation services.." Those procedures were implemented July 1 2022.
It was observed that clinicians failed to document type and frequency of treatment on the client Treatment plan reviews. A new treatment plan review document was developed that made clear that type and frequency must be filled out for the review to be signed. This policy went into effect on 9/1/2022 and will be updated in the Addictions treatment manual as an amendment.
It is the project directors responsibility to disseminate the new directive and the facility directors responsibility to enforce its implementation. The corrective action plan was reviewed with Agency staff and implemented on 8/5/2022
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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 proposed type of support service on individual treatment plans in two out of three applicable records reviewed.
Client #1 was admitted on March 15, 2022 and was still active at the time of the inspection. The treatment plan was dated April 14, 2022.
Client #3 was admitted on October, 22, 2021 and was still active at the time of the inspection. The treatment plan was dated November 3, 2022.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The project director established Master treatment Plan Policies and procedures. Proper completion of required intake paperwork including but not limited to "Proposed type of support service.as outlined in the Master treatment plan " Those procedures were implemented July 1 2022.
It was observed that clinicians failed to document Proposed type of support service of treatment on the client Treatment plan reviews.
The facility will reeducate all staff on the proper completion of the treatment Plan reviews.
Client #1 will have their TPR updated on their next scheduled appointment.
The corrective action plan was reviewed with Agency staff and implemented on 8/5/2022
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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.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in five out of five applicable records reviewed.
Client #1 was admitted on March 15, 2022 and was still active at the time of the inspection. A treatment plan was completed on April 14, 2022 and the next update was due no later than June 14, 2022; however, no update was completed.
Client #2 was admitted on April 27, 2022 and was still active at the time of the inspection. A treatment plan update was completed on March 8, 2022 and the next update was due no later than May 8, 2022; however, no update was completed.
Client #3 was admitted on October 22, 201 and was still active at the time of the inspection. A treatment plan update was completed on March 17, 2022 and the next update was due no later than May 17, 2022; however, no update was completed.
Client #4 was admitted on January 10, 2022 and was still active at the time of the inspection. A treatment plan was completed on March 4, 2022 and the next update was due no later than May 4, 20221; however, it was not completed until June 9, 2022.
Client #7 was admitted on October 8, 2018 and discharged on June 2, 2022. A treatment plan update was completed on September 2, 2021 and the next update was due no later than November 2, 2021; however, it was not completed until January 14, 2022.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The project director established Treatment Plan Reviews Policies and procedures. Proper completion of required intake paperwork including but not limited to "Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days." Those procedures were implemented July 1 2022
In all client files observed the clinician failed to document their Treatment plan reviews in regards to policies and procedures.
It is the responsibility of the Facility to train existing new staff on proper PNP.
Client # 2 will have an updated TRP on their next scheduled appointment.
Client #3 will have an updated TRP on their next scheduled appointment.
Client #4 will have an updated TRP on their next scheduled appointment.
Client #7 was discharged and therefore no update could be completed.
The corrective action plan was implemented and The staff was retrained on policies on 8-5-2022 as a review of the audit
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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.
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Observations
Based on a review of client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in three out of four applicable records reviewed.
Client #1 was admitted on March 15, 2022 and was still active at the time of the inspection. The treatment plan dated April 14, 2022 indicated one hour of individual sessions weekly. There was no documentation of the client receiving individual therapy between April 14-June 23, 2022.
Client #3 was admitted on October 22, 2021 and was still active at the time of the inspection. The treatment plan dated November 3, 2021 indicated individual sessions weekly. There was no documentation that the client received individual therapy March 17 - April 28, 2022 and April 29- June 1, 2022.
Client #4 was admitted on January 10, 2022 and was still active at the time of the inspection. The treatment plan dated March 4, 2022 indicated individual and group sessions weekly. There was no documentation that the client received individual therapy between June 9-August 3, 2022. In addition, there was no documentation that the client received group therapy between April 8-August 3, 2022.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The project director established Master Treatment Planning Policies and procedures. Proper completion of required intake paperwork including but not limited to "Type and frequency of treatment and rehabilitation services.." Those procedures were implemented July 1 2022.
It was observed that clinicians failed to document By way of signed Encounter form and or progress note of the session . It the responsibility of clinicians to document all interactions with the client by way of progress note. The clinician is responsible to document all No shows cancelation and rescheduled appointments as well as clinical sessions . The Facility director will audit weekly to assure that all documentation is completed.
It is furthermore the responsibility of all agency staff to provide the level of treatment that each client requires as part of their level of care .
The agency staff responsible for these citations are no longer with the agency . The current staff will document when they took over care for the clients and maintain proper paperwork moving forward. This policy was implemented on July 1 2022
Client #3 had sporadic treatment attendance . thus explaining the lapse of treatment .
Client #4 had sporadic attendance during this time period . The clinician will document all attempts to engage the client .
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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 the review of client records, the facility failed to document case consultations within the regulatory timeframe in six out of seven applicable client records. The facility's policy and procedures manual states that all clients will have a case consultation quarterly from date of intake.
Client #1 was admitted on March 15, 2022 and was still active at the time of the inspection. A case consultation was completed on March 15, 2022 and the next case consultation was due no later than June 15, 2022: however, none has been completed.
Client #2 was admitted on April 27, 2021 and was still active at the time of the inspection. A case consultation was completed on January 11, 2022 and the next one would be due no later than April 11, 2022; however, none has been completed.
Client #3 was admitted on October 22, 2021 and was still active at the time of the inspection. A case consultation was completed on March 22, 2022 and the next one would be due no later than June 22, 2022; however, none has been completed.
Client #4 was admitted on January 10, 2022 and was still active at the time of the inspection. A case consultation was completed on April 8, 2022 and the next one would be due no later than July 8, 2022; however, none has been completed.
Client #6 was admitted on January 10, 2022 and discharged on July 7, 2022. A case consultation was completed on December 17, 2021 and the next one would be due no later than March 17, 2022; however, it was not completed until April 7, 2022.
Client #7 was admitted on October 8, 2018 and was discharged June 2, 2022. A case consultation was completed on October 13, 2021 and the next one would be due no later than January 13, 2022; however, none had been completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project director established Intake Policies and procedures. Proper completion of required intake paperwork including but not limited to "Case consultation notes." Those procedures were implemented July 1 2022.
It is the responsibility for the facility director to instruct all agency staff on proper policies and procedures of Case consultation . Pg 57 in the addictions manual clearly conveys the policy of frequency of case consultation "It is the policy of the PATH Licensed Outpatient Drug and Alcohol Program to
review each client's progress every 90 days at a case conference consisting of representatives from the various client service components. Case Consultations can include just the clinical staff person and one other clinician (Facility Director). Case Consultation notes are documented on the Case Consultation Form."
The project director has instructed the facilities director to update all case consultations for all active clients and document that in the clients' charts. If the client has been discharged, then no further update is possible.
Client #1 Case consultation was completed on 8/15/22
Client#2 Case consultation will be completed on His next appointment 10/12/22
Client #3 Case consult will be completed on 9/27/2022
Client #4 case consult will be completed on next appointment 9/20/22
Client #6 was discharged 4/7/22 no correction completed
Client #7 was deceased on 6/7/22 no correction completed
The corrective action plan was implemented and The staff was retrained on policies on 8-5-2022 as a review of the audit
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