INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 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, Silver Linings USA Limited Liability Company 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 the project director/facility director met the appropriate experiential qualifications for the position in one of one applicable personnel record reviewed. Employee #1 was hired as the project director/facility director on November 15, 2021. The personnel record documented that the employee had a qualifying master's degree; however, the employee did not have any documented experience in program planning prior to being hired.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Operations Manager was not hired as facility director but did assume responsibilities in April 2022 when the previous director left the agency.
At time of hire, or staff assuming new responsibilities the CEO or HR representative will review their credentials and resume to ensure that they meet all required qualifications for the position/role. This will be documented in their personnel file that the review took place and the qualifications were met. |
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
Based on a review of personnel records, the facility failed to ensure that all staff persons received at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in one of one applicable personnel record reviewed. Employee # 4 was hired as a counselor on April 27, 2021 and was due to have the TB/STD training no later than April 27, 2022; however, the 4-hour TB/STD training was not completed at the time of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All incoming staff will be required to be signed up for or scheduled for TB/STD and HIV trainings by the conclusion of their 90 day orientation period. Failure to have scheduled the trainings for 4 hours of TB/STD and 6 Hours of HIV will result in an extension of the staff's probationary period until they are signed up for the appropriate trainings to have all required hours completed within their first year of employment.
This will be added to the New Employee Orientation checklist and kept in their Personnel File.
The staff that were non-compliant have been required to sign up for and attend TB/STD training through Willow Communication Strategies by 10/15/2022. |
705.28 (d) (2) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(2) Conduct fire drills during normal staffing conditions.
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Observations
Based on a review of the October 2021 through August 2022 fire drill logs, the facility failed to conduct fire drills during normal staffing conditions for the months of January, February, and August 2022. The fire drill logs for the months listed indicated that the fire drills were conducted outside of the facility's posted operating hours of Monday through Thursday from 8:30am to 8:30pm, Friday from 8:00am to 4:00pm and Saturday from 9:00am to 12:00pm.This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facility staff were instructed not to schedule fire drills on days that were designated for client make up days/times that are outside of typical business hours.
All facility fire drills will be conducted during posted operating hours of Monday through Thursday from 8:30am to 8:30pm, Friday from 8:00am to 4:00pm and Saturday from 9:00am to 12:00pm.
Operations Manager will approve fire drill dates and times with staff conducting the drills. |
709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
Based on an administrative review, the facility failed to document, and make available to the public, an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors, and principal shareholders. This finding was discussed with facility staff during the licensing process.
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Plan of Correction
The Chief Executive Officer will prepare an annual report including a statement disclosing the names of officers, directors, and principal shareholders for Silver Linings USA, LLC for each operating year and will publish in the Newtown Gazette and add describing the process to request to review the annual reports. |
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 complete an informed and voluntary consent to release information form prior to the disclosure of information in two of fourteen client records reviewed. Client # 6 was admitted to the partial hospitalization activity on May 25, 2022 and was discharged on June 19, 2022. 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 # 10 was admitted to the outpatient activity on June 20, 2022 and was still active at the time of the 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. This is a repeat citation from the September 21, 2021 annual licensing renewal inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will have a specific funding source release of information added into the electronic medical record by 10/18/2022, this request was made to the software company on 10/14/2022.
The Funding Source ROI will be populated in the electronic medical record and presented for the active client #10 to sign for their specific funding source by 10/18/2022.
This form will be completed at time of admission going forward with all clients by admissions staff. Current clients will also sign the funding source release of information form with their primary therapists if there is not one previously documented in their electronic medical record by 10/20/22.
The Operations Manager has created an admissions checklist that all staff completing an admission will be required to fill out for all assessed clients and upload into the electronic medical record. The Funding Source ROI will be incorporated into this checklist. The checklist will be required starting 10/18/2022.
The Clinical Lead will begin reviewing the admission checklists uploaded by admissions staff for completeness and that chart audit that all required forms, including the Funding Source ROI were completed correctly within 48 of assessment date with a start date of 10/18/2022. |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom the disclosure is made on a consent to release information forms in one of fourteen client records reviewed. Client # 1 was admitted to the partial hospitalization activity on June 27, 2022 and was still active at the time of the inspection. There was a blank release of information form and a release of information form to the referral source that were signed and dated by the client on June 27, 2022; however, both forms failed to include the name of the person, agency, or organization to whom the disclosures would be made. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will no longer send out release of information forms via the digital method built into the electronic medical record system. It was discovered that the forms were able to be signed digitally by the client without having to fill in the fields that are meant to be completed.
Due to this, all release of information forms will be completed in person with admission staff, or primary therapists going forward so that all clients release of information forms will include and document the name of the person, agency, or organization to whom the disclosure is made.
The Operations Manager has created an admissions checklist that all staff completing an admission will be required to fill out for all assessed clients and upload into the electronic medical record. The authorization for release of information will be incorporated into this checklist. The checklist will be required starting 10/18/2022.
The Clinical Lead will begin reviewing the admission checklists uploaded by admissions staff for completeness and then chart audit that all required lines of the form are completed, including the name of the person, agency, or organization to whom the disclosure is made within 48 of assessment date with a start date of 10/18/2022.
Client #1 was presented with a new release of information form and the required lines for he name of the person, agency, or organization to whom the disclosure is made have been completed properly on 10/12/2022. |
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 document the specific information to be disclosed on consent to release information forms in one of fourteen client records reviewed. Client # 1 was admitted to the partial hospitalization activity on June 27, 2022 and was still active at the time of the inspection. The release of information form to the referral source was signed and dated by the client on June 27, 2022; however, the release form failed to include the specific information to be disclosed. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will no longer send out release of information forms via the digital method built into the electronic medical record system. It was discovered that the forms were able to be signed digitally by the client without having to fill in the fields that are meant to be completed.
Due to this, all release of information forms will be completed in person with admission staff, or primary therapists going forward so that all clients release of information forms will include and document the specific information to be disclosed.
The Operations Manager has created an admissions checklist that all staff completing an admission will be required to fill out for all assessed clients and upload into the electronic medical record. The authorization for release of information will be incorporated into this checklist. The checklist will be required starting 10/18/2022.
The Clinical Lead will begin reviewing the admission checklists uploaded by admissions staff for completeness and then chart audit that all required lines of the form are completed, including the specific information to be disclosed within 48 of assessment date with a start date of 10/18/2022.
Client #1 was presented with the updated ROI form on 10/15/2022 to sign via electronic medical system. This is now present in the client's chart. |
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 the purpose of the disclosure on release of information forms in eight of fourteen client records reviewed.Client # 1 was admitted to the partial hospitalization activity on June 27, 2022 and was still active at the time of the inspection. The release of information form to the referral source was signed and dated by the client on June 27, 2022 and the release of information form to the pharmacy was signed and dated by the client on June 28, 2022; however, both forms did not include the purpose of the disclosure. Client # 3 was admitted to the partial hospitalization activity on September 2, 2022 and was still active at the time of the inspection. The release of information form to the pharmacy was signed and dated by the client on September 6, 2022; however, the form did not include the purpose of the disclosure. Client # 4 was admitted to the partial hospitalization activity on January 13, 2022 and was discharged on February 6, 2022. The release of information form to the pharmacy was signed and dated by the client on January 13, 2022; however, the form did not include the purpose of the disclosure. Client # 5 was admitted to the partial hospitalization activity on February 7, 2022 and was discharged on April 17, 2022. Two release of information forms to the pharmacy were signed and dated by the client on February 8, 2022 and March 30, 2022; however, both forms did not include the purpose of the disclosure. Client # 8 was admitted to the outpatient activity on February 7, 2022 and was still active at the time of the inspection. The release of information form to the pharmacy was signed and dated by the client on January 13, 2022; however, the form did not include the purpose of the disclosure. Client # 9 was admitted to the outpatient activity on April 18, 2022 and was still active at the time of the inspection. Two release of information forms to the pharmacy were signed and dated by the client on February 8, 2022 and March 30, 2022; however, both forms did not include the purpose of the disclosure. Client # 11 was admitted to the outpatient activity on December 27, 2021 and was discharged on January 5, 2022. The release of information form to the pharmacy was signed and dated by the client on December 27, 2021; however, the form did not include the purpose of the disclosure. Client # 12 was admitted to the outpatient activity on April 18, 2022 and was discharged on August 23, 2022. The release of information form to the pharmacy was signed and dated by the client on April 18, 2022; however, the form did not include the purpose of the disclosure. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will no longer send out release of information forms via the digital method built into the electronic medical record system. It was discovered that the forms were able to be signed digitally by the client without having to fill in the fields that are meant to be completed.
Due to this, all release of information forms will be completed in person with admission staff, or primary therapists going forward so that all clients release of information forms will include and document the purpose of the disclosure.
The Operations Manager has created an admissions checklist that all staff completing an admission will be required to fill out for all assessed clients and upload into the electronic medical record. The authorization for release of information will be incorporated into this checklist. The checklist will be required starting 10/18/2022.
The Clinical Lead will begin reviewing the admission checklists uploaded by admissions staff for completeness and then chart audit that all required lines of the form are completed, including the specific information to be disclosed within 48 hours of assessment date with a start date of 10/18/2022.
Client #1 was presented with the updated release of information form for pharmacy on 10/15/2022 to sign via electronic medical system. This is now present in the client's chart and reflects the specific information to be disclosed.
Client #3 was presented with the updated release of information form for pharmacy on 10/15/2022 to sign via electronic medical system. This is now present in the client's chart and reflects the specific information to be disclosed.
Client #8 was presented with the updated release of information form for pharmacy on 10/15/2022 to sign via electronic medical system. This is now present in the client's chart and reflects the specific information to be disclosed.
Client #9 was presented with the updated release of information form for pharmacy on 10/15/2022 to sign via electronic medical system. This is now present in the client's chart and reflects the specific information to be disclosed.
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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
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified that 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 and that no client may be deprived of a civil right solely by reason of treatment in fourteen of fourteen client records reviewed. In every client record reviewed, the client rights acknowledgement form did not include notification of this client right.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The client rights form has been updated to in the electronic medical record to include and document the written acknowledgement by clients that they have been notified that 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 and that no client may be deprived of a civil right solely by reason of treatment.
All new admissions and current clients will be presented with the updated Client Rights form for signature of understanding as soon as the form is available in the electronic medical record system. |
709.30 (2) 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.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified that the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion in fourteen of fourteen client records reviewed.In every client record reviewed, the non-discrimination rights acknowledgement form was missing creed, color, national origin, marital status, and religion.This is a repeat citation from the September 21, 2021 annual licensing renewal inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Client Rights form will be updated to include creed, color, national origin, marital status, and religion under the right to non-discriminatory services section.
All new admissions, and current clients will be presented with the new form for signature once it is available in the electronic medical record system. |
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
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right to inspect their own records, that 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 and that reasons for removing sections shall be documented in the record in fourteen of fourteen client records reviewed.In every client record reviewed, the client rights acknowledgement form did not include notification of this client right.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Client Rights form will be updated to document the written acknowledgement by clients that they have been notified of their right to inspect their own records, that 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 and that reasons for removing sections shall be documented in the record.
Once updated in the electronic medical record system all new admissions, and current clients will be presented the new Client Rights form for signature. |
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
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right to appeal a decision limiting access to their records to the director in fourteen of fourteen client records reviewed.In every client record reviewed, the client rights acknowledgement form did not include notification of this client right.This is a repeat citation from the September 21, 2021 annual licensing renewal inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Client Rights form will be updated to document the written acknowledgement by clients that they have been notified of their right to of their right to appeal a decision limiting access to their records to the director.
The new Client Rights form is now active in the electronic medical records as of 10/15/2022 and all new admissions, and current clients will be presented the new Client Rights form for signature beginning 10/15/2022. |
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
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right to request the correction of inaccurate, irrelevant, outdated, or incomplete information in their records in fourteen of fourteen client records reviewed.In every client record reviewed, the client rights acknowledgement form did not include notification of this client right.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Client Rights form will be updated to document the written acknowledgement by clients that they have been notified of their right to request the correction of inaccurate, irrelevant, outdated, or incomplete information in their records.
The new Client Rights form is now active in the electronic medical records as of 10/15/2022 and all new admissions, and current clients will be presented the new Client Rights form for signature beginning 10/15/2022. |
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
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right to submit rebuttal data or memoranda to their own records in fourteen of fourteen client records reviewed.In every client record reviewed, the client rights acknowledgement form did not include notification of this client right.This is a repeat citation from the September 21, 2021 annual licensing renewal inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Client Rights form will be updated to document the written acknowledgement by clients that they have been notified of their right to submit rebuttal data or memoranda to their own records.
The new Client Rights form is now active in the electronic medical records as of 10/15/2022 and all new admissions, and current clients will be presented the new Client Rights form for signature beginning 10/15/2022. |
709.34 (c) (4) 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:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of the facility's October 2021 through September 2022 unusual incident logs, the facility failed to file a written unusual incident report with the Department within 3 business days following an event that required the presence of police and/or ambulance personnel at the facility on January 5, 2022. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will be re-trained on the internal incident reporting forms by 10/21/22. The forms now have added lines to check off that include the reportable incident type if they are applicable to the incident.
These include:
1. Physical or sexual assault by staff or a client.
2. Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
3. A significant disruption of services due to a disaster or another occurrence that results in the closure of a facility for more than 1 day.
4. Event at the facility requiring the
presence of police, fire or ambulance
personnel.
5. Outbreak of a contagious disease.
The Operations Manager will review and sign off on any newly completed internal incident reporting forms and determine if an unusual incident requires that the incident be reported to DDAP within 3 business days. This will include1. Physical or sexual assault by staff or a client.
2. Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
3. A significant disruption of services due to a disaster or another occurrence that results in the closure of a facility for more than 1 day.
4. Event at the facility requiring the
presence of police, fire or ambulance
personnel.
5. Outbreak of a contagious disease.
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709.82(a)(2) LICENSURE Treatment and rehabilitation services
709.82. 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 client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual client's treatment and rehabilitation plan in four of seven applicable partial client records reviewed.Client # 1 was admitted to the partial hospitalization activity on June 27, 2022 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on June 29, 2022; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services. Client # 2 was admitted to the partial hospitalization activity on August 30, 2022 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on September 1, 2022; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services. Client # 3 was admitted to the partial hospitalization activity on September 2, 2022 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on September 7, 2022; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services. Client # 6 was admitted to the partial hospitalization activity on May 25, 2022 and was discharged on June 19, 2022. The individual treatment and rehabilitation plan was completed on May 31, 2022; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Operations Manager requested that the electronic medical record software provider update the Initial Treatment plan, Master Treatment Plan, and Treatment Plan review to document the type and frequency of treatment services being provided.
The change was requested 10/14/2022 and will be effective 10/18/2022. The admissions checklist includes the initial treatment plan as part of the admission process to include level of care, and frequency of attendance. The Master treatment plan and Treatment plan updates will require the level of care and frequency of attendance to be completed prior to a therapist moving on to the next part of the treatment plan. All treatment plans will be reviewed by the Clinical Lead and signed.
All current clients with previous treatment plans that become due for treatment plan updates will have their treatment plan updates reflect the changes and document their type of treatment/level of care and frequency of attendance.
All admitted clients after 10/18/2022 will have the type of treatment/level of care documented in their Initial, Master and Treatment Plan review documentation going forward. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of client records, the facility failed to review and update treatment and rehabilitation plans at least every thirty days in one of two applicable client records reviewed. Client # 1 was admitted to the partial hospitalization activity on June 27, 2022 and was still active at the time of the inspection. The individual treatment plan was completed on June 29, 2022 and an update was due no later than July 29, 2022; however, there was no update completed at the time of the inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Operations Manager and Clinical Lead have developed a chart audit form for all therapists to use to keep track of their caseload and ensure that clients admitted to the program receive treatment plan updates every 15 days for Partial Hospital level of care as per the agencies policy, and every 60 days for Intensive Outpatient and Outpatient levels of care.
All therapists are using the self audit form as of 10/15/2022.
The therapists are responsible for completion of their self audit forms, and discussing in clinical meeting on Tuesday afternoons their progress in completing treatment plan updates on time.
In an instance that a therapist is unable to complete the treatment plan update in the required time frame the Clinical Lead will complete the treatment plan update and present it to the patient by the due date.
Client #1 treatment plan update has been completed by primary therapist as of 10/15/2022. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of client records, the facility failed to ensure that clients admitted to the partial hospitalization program received individual counseling services at least twice a week in four of six applicable client records. Client # 1 was admitted to the partial hospitalization activity on June 27, 2022 and was still active at the time of the inspection. The record of service and progress notes indicated that there were no individual counseling sessions during the weeks of July 10, 2022 through July 23, 2022, July 31, 2022 through August 6, 2022, and August 14, 2022 through August 20, 2022. Additionally, there was only 1 individual counseling session per week during the weeks of July 3, 2022 through July 9, 2022, July 24, 2022 through July 30, 2022, August 7, 2022 through August 13, 2022, and August 21, 2022 through September 3, 2022. Client # 2 was admitted to the partial hospitalization activity on August 30, 2022 and was still active at the time of the inspection. The record of service and progress notes indicated that there was only 1 individual counseling session during the week of September 4, 2022 through September 10, 2022.Client # 4 was admitted to the partial hospitalization activity on January 13, 2022 and was discharged on February 6, 2022. The record of service and progress notes indicated that there were no individual counseling sessions during the week of January 30, 2022 through February 5, 2022. Additionally, there was only 1 individual counseling session during the week of January 23, 2022 through January 29, 2022. Client # 5 was admitted to the partial hospitalization activity on February 7, 2022 and was discharged on April 17, 2022. The record of service and progress notes indicated that there were no individual counseling sessions during the week of February 13, 2022 through February 19, 2022. Additionally, there was only 1 individual counseling session per week during the weeks of February 20, 2022 through March 19, 2022. This is a repeat citation from the September 21, 2021 annual licensing renewal inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Operations Manager and Clinical Lead have developed a chart audit form for all therapists to use to keep track of their caseload and ensure that clients admitted to the partial hospitalization program receive individual counseling services at least twice per week.
All therapists are using the self audit form as of 10/15/2022.
The therapists are responsible for completion of their self audit forms, and discussing in clinical meeting on Tuesday afternoons any instances that arise that require a patient to be rescheduled, or a therapist or the patient to be unavailable for 2 sessions in the same week with the Clinical Lead.
In cases when a therapist is not in the office and a patient at the Partial Hospital Level of care requires individual sessions an assigned on duty therapist will cover the sessions that are required and document the session in an DAP Individual Session Note in the patient chart.
In cases when the patient does not show or cancels for a scheduled individual session the therapists will be responsible to enter a Missed DAP Individual Session note, and if applicable make an attempt at outreaching the client to re-engage them.
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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 review and update treatment and rehabilitation plans at least every sixty days in six of six applicable client records reviewed. Client # 8 was admitted to the outpatient activity on February 7, 2022 and was still active at the time of the inspection. The individual treatment plan was completed on April 14, 2022 and an update was due no later than June 14, 2022; however, the update was not completed at the time of the inspection. Client # 9 was admitted to the outpatient activity on April 18, 2022 and was still active at the time of the inspection. The individual treatment plan was completed on May 25, 2022 and an update was due no later than July 25, 2022; however, the update was not completed at the time of the inspection. Client # 10 was admitted to the outpatient activity on June 20, 2022 and was still active at the time of the inspection. The individual treatment plan was completed on June 20, 2022 and an update was due no later than August 20, 2022; however, the update was not completed at the time of the inspection. Client # 12 was admitted to the outpatient activity on April 18, 2022 and was discharged on August 23, 2022. The individual treatment plan was completed on April 25, 2022 and an update was due no later than June 25, 2022; however, the update was not completed at the time of the inspection. Client # 13 was admitted to the outpatient activity on September 20, 2021 and was discharged on June 30, 2022. A treatment plan update was completed on February 8, 2022 and an update was due no later than April 8, 2022; however, the update was not completed at the time of discharge. Client # 14 was admitted to the outpatient activity on November 17, 2021 and was discharged on April 21, 2022. A treatment plan update was completed on February 8, 2022 and an update was due no later than April 8, 2022; however, the update was not completed at the time of discharge. This is a repeat citation from the September 21, 2021 annual licensing renewal inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Operations Manager and Clinical Lead have developed a chart audit form for all therapists to use to keep track of their caseload and ensure that clients admitted to the program receive treatment plan updates every 15 days for Partial Hospital level of care, and every 60 days for Intensive Outpatient and Outpatient levels of care.
All therapists are using the self audit form as of 10/15/2022.
The therapists are responsible for completion of their self audit forms, and discussing in clinical meeting on Tuesday afternoons their progress in completing treatment plan updates on time.
In an instance that a therapist is unable to complete the treatment plan update in the required time frame the Clinical Lead will complete the treatment plan update and present it to the patient by the due date.
Client #8, client #9, and Client #10 were all presented with treatment plan updates by their primary therapist as of 10/15/2022. |
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 document a complete client record, which is to include follow-up information, in one of three applicable client records reviewed.Client # 14 was admitted to the outpatient activity on November 17, 2021 and was discharged on February 21, 2022. The client record did not document follow-up information as of the date of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Alumni Program/Discharge Follow up forms are now being presented to clients at intake by peer support specialists for consent/signature as of 10/15/22. Previously they were being sent digitally but this process was not sufficient.
The Admissions Representative is able to pull a list of all clients that have consented to follow up phone calls/alumni involvement following discharge from the electronic medical record software system.
The Admissions Representative is now responsible for completing all follow up calls weekly that are compiled onto the list.
The Director of Strategic Partnerships will be responsible for ensuring that Admissions Representative has completed the lists weekly for all follow ups scheduled.
If the Admissions Representative is unable to complete, or scheduled off then the Director of Strategic Partnerships will make the follow up outreach for the duration of the needed coverage. |